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COPYRIGHT DEPOSIT. 



1 LIVING ANATOMY 
AND PATHOLOGY 



THE DIAGNOSIS OF DISEASES 

IN 

EARLY LIFE 

BY THE 

ROENTGEN METHOD 



BY 

THOMAS MORGAN ROTCH, M.D. 

PROFESSOR OP PEDIATRICS, HARVARD UNIVERSITY 



THREE HUNDRED AND THREE ILLUSTRATIONS 




PHILADELPHIA &? LONDON 

J. B. LIPPINCOTT COMPANY 






Copyright, 1910 
By J. B. LiPPiNGOTT Company 



Printed by J. /?. Lippincott Company 
The Washington Square I'ress, Philadelphia, U.S.A. 



<&CU<:^ 



TO 
WILLIAM OSLER, M.D., F.R.S. 

REGIUS PROFESSOR OF MEDICINE, OXFORD UNIVERSITY 

IN RECOGNITION OF THE AID WHICH 

HE HAS GIVEN TO THE DEVELOPMENT 

OF THE SUBJECT OF PEDIATRICS 



PREFACE 



The Roentgen ray has been largely used as an aid to diagnosis 
in both early and later life. Its mechanism has been fully explained 
in various books, but a systematic exposition of the practical results 
of the Roentgen method of examination has not yet appeared. 

The purpose of this book is to deal as little as possible with the 
questions of apparatus and technic and to devote the entire space to 
the actual clinical teaching of the subject. 

This teaching is accomplished by means of illustrative plates, 
by legends corresponding to them, and by a text explanatory of 
what can really be seen in health and in disease in early life. 

The book is devoted to the diagnosis of disease and does not 
deal to any extent with treatment. It is intended to provide a 
means by which a fair knowledge of the Roentgen method can be 
acquired by the student when the personal instruction of a skilled 
Roentgenologist is not available. 

I believe that in teaching Roentgenology it is of the utmost 
importance to present illustrations of evident conditions and not 
to mislead the student with vague descriptions. In the plates I 
have been careful not to allow any retouching whatever, and I have 
discarded those which would have to be altered in order to show 
what would be described in the legends. Unless this is done the 
plates are reduced to diagrams and lose their value for accuracy and 
for teaching the student to interpret them independently. 

The plates are placed opposite to the legends, and the illustra- 
tions and details are given to the student as would be done if an 



vi PREFACE. 

expert Roentgenologist were standing beside him describing the plate 
by means of an illuminator. The different parts of the plate, whether 
normal or abnormal, are designated by leaders and by letters just 
as the Roentgenologist would designate them with his pointer. 

The two methods are in this way identical, excepting that the 
questions which the student may ask have to be anticipated in the 
legends. It is, therefore, important to make the legends cover what 
a fairly intelligent student can reasonably be expected to ask. It 
is important to explain in the text whether the different parts of 
the illustrations are normal or abnormal. This is not only to antic- 
ipate possible questions, but in order that the student may learn 
to distinguish normal conditions, and by studying the reproduc- 
tions methodically, recognize the normal in his search for the 
abnormal. 

In this sense the recognition of the normal becomes as impor- 
tant as does that of the abnormal, and the student is taught not 
to overlook anything — not even an artifact. 

By this method, if reference is made to previous normal illus- 
trations, the abnormal can readily be compared with the normal 
conditions of the same part. The knowledge acquired from this 
book will thus approach very closely to that obtained from the 
living instructor, and the student's power of original observation 
will be strengthened and improved. 

Believing, as I do, that in the study of diseases a knowledge 
of normal conditions should first be mastered, I have begun my 
illustrations by showing a set of normal Roentgenographs covering 
the different stages of development from a late period of intra-uter- 
ine life through childhood. 

I have then given the results of my study of the bones of the 
wrist, so as to exemplify what especial practical use can be made 
from an exact knowledge of the living anatomy of an especial part. 



PREFACE. vii 

I have next given examples of what can be seen in diseases of 
the new-born, such as the various congenital malformations and 
such abnormal conditions as are present at birth. 

By this portrayal of normal living anatomy and the grosser 
forms of the abnormal conditions the student is prepared to under- 
stand the finer pathologic lesions in the living subject. 

I have next shown the characteristic living lesions of the dis- 
eases of nutrition. I have then divided the book into certain 
groups which represent living pathologic conditions. Thus, in one 
division I have described the head and spine. In the next division 
I have given in detail what can be seen in Roentgenographs of the 
thorax, describing in succession abnormal conditions of the bronchial 
nodes, the bronchi, the lungs, the pleura, the pericardium, the heart, 
and aneurism. 

In the next division, the abdomen, I have been able to illus- 
trate the various conditions to only a limited degree, as this part of 
the infant and child presents great difficulties for the technic of the 
Roentgen method. 

Next I have shown how foreign bodies can be detected in dif- 
ferent parts of the trunk and extremities. Finally I have grouped 
under diseases of the extremities, for obvious technical reasons, a 
number of conditions of varying etiology. 

The material which illustrates the book has in most cases been 
taken from the Roentgen records of the Children's Hospital, and I 
wish to express my appreciation of the courtesy of the Managers, 
who have permitted me to use what has amounted in the past year 
to over two thousand and three hundred cases. 

The plates of the Roentgen illustrations were taken by Dr. 
Arial W. George, and in their unusual excellence speak for them- 
selves. To Dr. George I can only express my appreciation of his 
skill and the ever new light which he has thrown upon a somewhat 
difficult subject by his clear and original interpretation. 



viii PREFACE. 

To Dr. Percy Brown I owe my thanks for much expert advice 
on subjects connected with the writing of the book and for the plates 
illustrating long and short exposures. 

To Dr. Walter Curtis Miner I wish to express my appreciation 
of his work in connection with those illustrations which represent 
the development of the teeth and their anomalies. What is shown 
in these dental Roentgenographs will be of great service not only 
to the oral surgeon but to the orthodontist and to the general 
practitioner. 

Dr. William Palmer Lucas has given much practical aid in 
many ways connected with the book, and to him are due my 
thanks. 

I offer this work to the Medical Profession in the hope that it 
may be of assistance in solving many of the more difficult problems 
which arise in the diagnosis of disease in early life. 

THOMAS MORGAN ROTCH. 



197 Commonwealth Avenue, Boston, Massachusetts, 
January, 1910. 



TABLE OF CONTENTS 



PAGE 

INTRODUCTION 1 

DIVISION I. 

LIVING NORMAL ANATOMY 17 

Bone; Periosteum; The Constituents of Bone; Diaphyses and Epiphyses; Time of 
the Appearance of the Epiphyses; Development of Bone; Humerus; Radius; Ulna; 
Carpus; Metacarpus; Phalanges; Femur; Patella; Tibia; Fibula; Tarsus; Meta- 
tarsus; Phalanges; Os Innominatum; Teeth; Temporary Teeth; Permanent Teeth; 
Chronologic Examples of Normal Living Anatomy. 

DIVISION II. 

ILLUSTRATIVE USE OF LIVING NORMAL ANATOMY 49 

Key to Index Development; State Laws regarding Child Labor. 

DIVISION III. 

DISEASES OF THE NEW-BORN 69 

Anomalies of the Head, Spine, and Ribs; Spina Bifida; Intra-thoracic and Intra- 
abdominal Anomalies; Anomalies of the Extremities and Pelvis; Backward Mental 
Development; Myxcedema; Cretinism; Chondrodystrophia Fcetalis; Achondro- 
plasia; Osteogenesis Imperfecta; Fetal Rhachitis; Obstetrical Paralysis. 

DIVISION IV. 

DISEASES OF NUTRITION 95 

Osteomalacia 96 

Infantile Atrophy 99 

Scorbutus 100 

Rhachitis 104 

Rhachitis of Adolescence 112 

DIVISION V. 

DISEASES OF THE HEAD AND SPINE 115 

Supernumerary Teeth; Non-tubercular Infections of Spine; Osteomyelitis of Spine; 
Tuberculosis of Spine. 

ix 



x TABLE OF CONTENTS. 

DIVISION VI. 

THE BRONCHIAL NODES — BRONCHI — LUNGS — PLEURA — HE ART — PERI- 
CARDIUM— ANEURISM 131 

Bronchial Nodes 132 

Tuberculosis. 

Bronchi 133 

Lungs 133 

Atelectasis; Emphysema; Gangrene; Tuberculosis; Hydropneumothorax; Pneumo- 
thorax; Bronchopneumonia; Pneumonia. 

Pleura 137 

Empyema. 

Heart 139 

Pericardium 139 

Aneurism 140 

DIVISION VII. 

THE ABDOMEN 141 

Hour-glass Contraction of Stomach; Enlarged Mesenteric Nodes. 

DIVISION VIII. 

FOREIGN BODIES 143 

Urethra; (Esophagus; Larynx; Lung; Intestine; Hip; Knee-joint; Foot; Toe. 

DIVISION IX. 

EXTREMITIES 149 

Hand; Wrist; Foot; Abscess of Arm; Sarcoma; Atrophy; Poliomyelitis; Sub- 
periosteal Hemorrhage; Exostoses; Callus; Flat-foot; Traumatism; Fractures; 
Dislocations. 

JOINTS 163 

Knee: Congestion 166 

Epiphysitis 166 

Osteochondritis 166 

Suppuration of Epiphysis 167 

Villous Arthritis 167 

Ankylosis 168 

EPIPHYSITIS 175 

EPIPHYSIS 176 

Shoulder 176 

Elbow 176 

Wrist 177 

Hip 178 

Knee 178 

Ankle 179 

Os Caclis 179 



TABLE OF CONTENTS. xi 

Clavicle 179 

Acromion 179 

Coracoid Processes of Scapula 179 

Ribs 179 

Vertebrae 179 

Bones of Pelvis 179 

INFECTIOUS ARTHRITIS 181 

Humerus 185 

Hand 185 

Knee 185 

Femur 186 

RHEUMATIC FEVER 186 

Knee; Ankle. 

INFECTIOUS PERIOSTITIS 186 

OSTEOMYELITIS 187 

Tibia 189, 191, 195, 196 

Femur 190, 192, 195 

Hip 191 

Elbow 192 

Humerus 193 

Radius 193 

Fibula 196 

HYPERTROPHY AND ATROPHY OF JOINTS 197 

Wrists 197 

Hands 197 

Arms 197 

Knees 197 

Legs 197 

Ankles 197 

SYPHILIS 198 

Dactylitis 199 

Elbow 200 

Ulna 200 

Tibia 201 

Osteoperiostitis 201 

Osteochondritis 201 

Periostitis 201 

Retarded 202 

TUBERCULOSIS 202 

Atrophy 207 

Dactylitis 209, 610, 21 1 

Metatarsus 209 

Atrophy from Disuse 210 

Ulna: Necrosis 211 

Carpus 211 



xii TABLE OF CONTENTS. 

Elbow 211 

Hip 211, 212, 213 

Acetabulum 212 

Femur 212 

Knee 213, 214 

Thigh (Abscess) 214 

Ankle 215 

Astragalus 215 

Os Calcis 215 

NON-TUBERCULAR INFECTIONS 215 

Infection of Periosteum 217 

Infection of Marrow 217 



ILLUSTRATIONS 

(PLATES ARE GROUPED AT THE END OF THE DIVISION THEY ILLUSTRATE.) 



PLATE DIV 

1. Examples of Comparative Density Introduction 

2. Premature Infant, seven months 

3. Normal Head, age ten days 

4. Normal Trunk and Legs, age ten days 

5. Normal Head, age ten weeks. 

6. Normal Pelvis, Leg, and Foot, age ten weeks 

7. Normal Hand, age three months 

8. Normal Thorax, Shoulders, and Elbows, age three months 

9. Normal Infant, age six months 

10. Normal Thorax, age twelve months 

11. Normal Infant, age two years 

12. Normal Infant, age three years 

13. Normal Knees, Lower Legs, and Ankles, age three years 

14. Normal Foot, age five years 

15. Normal Child, age six years 

16. Normal Shoulder, age six years 

17. Normal Elbow, age six years 

18. Normal Knee, age six years 

19. Normal Thorax, age six years 

20. Normal Hands, boy, age nine years 

21. Normal Child, age ten years 

22. Normal Knees, Lower Legs, and Foot, age ten years 

23. Normal Spine, age ten years 

24. Normal Child, age twelve years 

25. Normal Elbow, age twelve years 

26. Normal Thorax, boy, age twelve years 

27. Right Side of Head, boy, age thirteen years 

28. Normal Hand — Group A, girl, age six months I 

29. Normal Hand — Group B, girl, age two and three-fourths years I 

30. Normal Hand — Group C, girl, age two and three-fourths years I 

31. Normal Hand — Group D, boy, age two and one-fourth years I 

32. Normal Hand — Group E, girl, age three and one-half years I 

33. Normal Hand — Group F, girl, age five and one-half years I 

34. Normal Hand — Group G, girl, age six and one-half years I 

35. Normal Hand — Group H, girl, age six years I 

36. Normal Hand — Group I, girl, age six and three-fourths years I 

37. Normal Hand — Group J, girl, »ge eight and one-fourth years I 

38. Normal Hand — Group K, girl, age eleven and one-fourth years I 

39. Normal Hand — Group L, girl, age eleven and three-fourths years I 



xiv ILLUSTRATIONS. 

PLATE DIV. 

40. Normal Hand — Group M, girl, age thirteen and one-half years II 

41. Anomaly of Upper Cervical Vertebrae, boy, age six years Ill 

42. Spina Bifida Occulta, girl, age three and one-half years, photograph Ill 

43. Spina Bifida Occulta, a Roentgenograph of the same subject as Plates 42 and 44 Ill 

44. Spina Bifida Occulta, a Roentgenograph of the same subject as Plates 42 and 43 Ill 

45. Fusion of Ribs, Marked Scoliosis of Congenital Origin, child, age four years Ill 

46. Congenital Torticollis, boy, age six years Ill 

47. Congenital Elevation of Scapula, Left Side, boy, age six years Ill 

48. Congenital Elevation of Right Scapula, boy, age six years Ill 

49. Congenital Elevation of Right Scapula, infant, age six months Ill 

50. Webbed Fingers, Extra Digit Ill 

51. Congenital Deformity of Hands and Arms, boy, age ten years Ill 

52. Malformation of the Radius and Ulna, infant, age eight months Ill 

53. Congenital Dislocation of the Radius and Ulna, boy, age ten years Ill 

54. Congenital Deformity of Foot, boy, age eight years Ill 

55. Roentgenograph of a Congenital Deformity of the Foot Ill 

56. Undeveloped Foot, child, age three years Ill 

57. Congenital Delayed Development of the Right Leg, infant, age six months. (Morse) . Ill 

58. The Feet of the Same Subject as Plate 57 Ill 

59. Double Congenital Dislocation of the Hip, girl, age twelve and one-half years Ill 

60. Congenital Dislocation of the Left Femur, boy, age ten years Ill 

61. Atrophy in Size of Both Femora due to Paralysis of the Legs, infant, age two years . . . Ill 

62. An Anomalous Condition of the Second Metacarpal Bone Ill 

63. Retarded Development of Hand Corresponding with Retarded Development of Brain, 

boy, age four years and nine months Ill 

64. Myxcedema — Retarded Development, girl, age eight years Ill 

65. Irregular Development, girl, age twenty-seven months Ill 

66. Chondrodystrophia Fcetalis, girl, age five and one-half years, and boy, age thirteen 

and one-half years . . . . , Ill 

(67. Retarded Development of the Pisiform Bone and General Anomalous Condition Ill 

68. Osteogenesis Imperfecta, Hand and Forearm, girl, age two years Ill 

69. Osteogenesis Imperfecta, Leg-fractures, girl, age two years Ill 

'70. Osteogenesis Imperfecta, Leg-fractures, girl, age twenty-five months Ill 

71. Obstetrical Paralysis of the Left Arm Ill 

72. Obstetrical Paralysis of the Left Arm, Marked Atrophy, boy, age six years Ill 

73. Obstetrical Paralysis of the Right Shoulder, girl, age four months Ill 

74. Osteomalacia, girl, age seven years IV 

75. Infantile Atrophy, infant, age twelve months IV 

76. Infantile Scorbutus, Thickened Cortex and Periosteum, girl, age eleven months IV 

77. Infantile Scorbutus, Subperiosteal, girl, age eleven months IV 

78. Infantile Scorbutus, Organizing Clot and Haematoma of the Muscles, infant, age six 

months IV 

79. Infantile Scorbutus, same subject as Plate 78 IV 

80. Infantile Scorbutus — Infiltrated Muscles, infant, age two months IV 

81. Early Rhachitis, child, age three years IV 

82. Early Rhachitis, child, age two years IV 

83. Rhachitis, boy, age seven years. Photographs IV 

84. Early Rhachitis — Thickened Cortex — Wolff's Law, boy, age seven years IV 

85. Advanced Rhachitis, boy, age ten years IV 

86. Marked Rhachitis, boy, age seven years IV 



ILLUSTRATIONS. xv 

PLATE DIV. 

87. Protuberant Abdomen, Knock-knee, and Flat-foot, boy, age three years IV 

88. Rhachitis of Adolescence — Normal and Rhachitic Hands, boys, age thirteen years .... IV 

89. Rhachitis of Adolescence — Hand, child, age twelve years IV 

90. Fracture of Skull, boy, age thirteen years V 

91. Ethmoiditis, child., age three years V 

92. Osteomyelitis of Lower Jaw, colored boy, age twelve years V 

93. Amomalous Bicuspids — Left Side of Head, boy, age thirteen years V 

94. Anomalous Lower Biscupid — Right Side of Head, boy, age thirteen years V 

95. Unerupted Permanent Teeth — Right Side of Head, boy, age eight years V 

96. Supernumerary Tooth — Left Side of Head, boy, age fifteen years V 

97. Supernumerary Tooth — Right Side of Head, girl, age fourteen years V 

98. Supernumerary Tooth — Left Side of Head, girl, age fourteen years V 

99. Various Anomalous Conditions Connected with the Teeth V 

100. Rhachitis of Spine, colored boy, age six years V 

101. Osteomyelitis of Vertebrse, girl, age four years V 

102. Tuberculosis of the Spine, Ilium, and Left Hip V 

103. Tuberculosis of the Ilium V 

104. Tubercular Abscess of the Spine V 

105. Tuberculosis of the Spine, child, age four years V 

106. Tubercular Spine, the same subject as Plate 105, lateral view V 

107. Normal Thorax, girl, age seven years. Long exposure. (Brown) VI 

108. Normal Thorax, girl, age seven years. Short exposure. (Brown) VI 

109. Enlarged Bronchial Nodes, girl, age twelve years VI 

110. Transposition of Organs — Tuberculosis of the Lungs and Bronchial Nodes VI 

111. Pneumococcus Lobar Pneumonia VI 

112. Double Pneumococcus Lobar Pneumonia, boy, age twelve years VI 

113. Lobar Pneumonia, child, age ten years VI 

114. Unresolved Lobar Pneumonia, girl, age four years VI 

115. Lobar Pneumonia, girl, age twenty-seven months. Same subject as Plates 65, 116, 

and 117 VI 

116. Consolidation of Right Lung — Mongolian Idiot VI 

117. Lobar Pneumonia. Same subject as Plates 65, 115, and 116 VI 

118. Bronchopneumonia, child, age four years VI 

119. Pneumonia — Inhalation of China Doll's Arm. Same subject as Plates 148, 149, 

and 150 VI 

120. Acute Miliary Tuberculosis of the Lungs, boy, age ten years VI 

121. Early Miliary Tuberculosis of the Lungs, child, age three years VI 

122. Probable Old Tubercular Process of Lung — Calcification VI 

123. Emphysema, Gangrene, and Tuberculosis of the Left Lung, girl, age three years VI 

124. Acute Miliary Tuberculosis of Both Lungs, girl, age twelve years VI 

125. Hydropneumothorax, boy, age seven years. Same subject as Plates 126 and 127. ... VI 

126. Hydropneumothorax. Same subject as Plates 125 and 127 VI 

127. Pneumothorax. Same subject as Plates 125 and 126 VI 

128. Thickened Pleura, boy, age six years VI 

129. Pleurisy with Effusion, child, age eight years VI 

130. Collapsed Ribs, girl, age six years VI 

131. Encapsulated Empyema, boy, age ten years VI 

132. Dilated Heart, boy, age ten years VI 

133. Pericardial Effusion, child, age twelve years VI 

134. Enlarged Heart with Pericardial Effusion, child, age twelve years VI 



xvi ILLUSTRATIONS. 

PLATE ©IV. 

135. Pericardial Effusion and Obliteration of the Cardiohepatic Angle VI 

136. Aneurism, boy, age twelve years VI 

137. Normal Abdomen, boy, age nine years. Short exposure. (Brown) VII 

138. Normal Abdomen, boy, age nine years. Long exposure. (Brown). Same subject as 

Plate 137 VII 

139. Hour-glass Contraction of Stomach, infant, age five weeks VII 

140. Hour-glass Contraction of Stomach — Tube in Stomach. Same subject as Plate 139 . . VII 

141. Abdominal Ascites, girl, age twelve years VII 

142. Calcined Mesenteric Nodes VII 

143. Stone in Urethra, Encapsulating a Pin, girl, age thirteen years VIII 

144. Foreign Body in Intestine, boy, age five years VIII 

145. Foreign Body in (Esophagus VIII 

146. Hook in the Larynx, child, age four years VIII 

147. Nail in Right Lung VIII 

148. Doll's China Arm in Lung, girl, age four years. Same subject as Plates 119, 149, 

and 150 VIII 

149. Doll's China Arm in Lung. Same subject as Plates 119, 148, and 150, taken face down . VIII 

150. Doll's China Arm in Lung. Same subject as Plates 119, 148, and 149 VIII 

151. Penny in the Descending Colon VIII 

152. Needle in the Knee-joint. Same subject as Plate 153 VIII 

153. Needle in the Knee-joint. Same subject as Plate 152, different position VIII 

154. Needle in Foot. Same subject as Plate 155 VIII 

155. Needle in Foot. Same subject as Plate 154, different position VIII 

156. Needle in the Tissues around the Phalanx of the Little Toe VIII 

157. Retarded Development of Hand, boy, age eight years IX 

158. Premature Ossification of the Lower Epiphysis of the Radius — Sesamoid Bone, child, 

age thirteen years IX 

159. Delayed Development of the Scaphoid, boy, age six years IX 

160. Early Ossification of the Upper Epiphysis of the Tibia IX 

161. Cellulitis of Tissues of Left Arm, boy, age nine years IX 

162. Hsematoma of Heel, child, age twelve years IX 

163. Giant-celled Sarcoma of the Thigh, boy, age four and one-half years IX 

164. Medullary Sarcoma of the Lower Part of the Femur, boy, age twelve years IX 

165. Periosteal Sarcoma — Lower End of Femur, boy, age ten years IX 

166. Extreme Atrophy, boy, age thirteen years IX 

167. Anterior Poliomyelitis of the Right Hand and Wrist, infant, age eighteen months. ... IX 

168. Anterior Poliomyelitis of the Left Shoulder, boy, age twelve months IX 

169. Anterior Poliomyelitis of the Left Arm, child, age four years IX 

170. Subperiosteal Hemorrhage of the Left Leg IX 

171. Exostosis of Astragalus, boy, age twelve years IX 

172. Multiple Exostoses of Tibia and Fibula, boy, age five years IX 

173. Multiple Exostoses — Leg, boy, age five years IX 

174. Exostosis of the Lower Part of the Femur IX 

175. Exostosis of the Tibia, boy, age twelve years IX 

176. Calluses of Feet, girl, age ten years IX 

177. Abnormally High Arch of Foot, girl, age ten years IX 

178. Moderate Flat-foot, girl, age thirteen years IX 

179. Backward Displacement of the Inner Condyle of the Femur, boy, age twelve years. . . IX 

180. Fracture and Displacement of the Head of the Humerus IX 

181. Dislocation and Fracture of the Anatomic Head of the Humerus, boy, age eleven years IX 



ILLUSTRATIONS. xvii 



DIV. 



182. Fracture of the Neck of the Humerus, boy, age twelve years IX 

183. Impacted Fracture of the Surgical Neck of the Humerus, boy, age four years IX 

184. Dislocation of the Epiphysis of the Femur, boy, age five years IX 

185. Untreated but United Green-stick Fracture of the Tibia, boy, age eight years IX 

186. Intracapsular Fracture of the Femur, boy, age ten years IX 

187. Dislocation of the Lower End of the Femur, boy, age ten years IX 

188. Fracture of the Lower End of the Humerus with Inward Displacement of the Lower 

Fragment, boy, age ten years IX 

189. Green-stick Fracture of the Radius, girl, age twelve years IX 

190. Complete Fracture of the Lower Third of the Radius and Ulna with Impaction, child, 

age three to four years IX 

191. Complete Fracture of the Radius and Ulna, child, age three years IX 

192. Incomplete Fracture of the Lower End of the Tibia, infant, age twelve months IX 

193. Fracture of the Astragalus, boy, age eleven years IX 

194. Old Fracture of Tibia and Fibula, with Connecting Bridge IX 

195. Normal Foot, child, age ten years IX 

196. Fracture of Tibia with Compensatory Growth of Fibula, girl, age twelve years IX 

197. Congestion of the Knee in a Case of Chronic Arthritis, child, age six years IX 

198. Epiphysitis of the Knee-joint, boy, age one year IX 

199. Epiphysitis of the Upper Epiphysis of the Tibia, girl, age ten years IX 

200. Infectious Arthritis — Atrophic Type, girl, age three years IX 

201. Villous Arthritis, girl, age twelve years IX 

202. Ankylosis of Knee-joint, boy, age thirteen years IX 

203. Infectious Arthritis in Shoulder-joint, girl, age eight years IX 

204. Infectious Arthritis of Hands IX 

205. Infectious Arthritis of the Hand, boy, age four and one-half years IX 

206. Effusion in the Knee-joint, boy, age ten years IX 

207. Acute Arthritis of Right Hip, child, age eight months IX 

208. Rheumatic Fever — Knee-joint IX 

209. Rheumatic Fever — Ankle-joint IX 

210. Osteomyelitis of the Shaft of the Tibia, child, age nine years IX 

211. Chronic Osteomyelitis of the Shaft of the Femur IX 

212. The Results of an Acute Destructive Process in the Hips, child, age five years IX 

213. Osteomyelitis of the Upper Shaft of the Tibia and of the Epiphysis, boy, age eight years IX 

214. Acute Osteomyelitis of the Right Femur, child, age two years IX 

215. Chronic Osteomyelitis — Great Destruction of the Femur, child, age two years IX 

216. Osteomyelitis of Elbow, boy, age nine years IX 

217. Typhoidal Osteomyelitis, child, age eight years IX 

218. Osteomyelitis of the Lower End of the Radius, boy, age six years IX 

219. Osteomyelitis of Lower Arm IX 

220. Osteomyelitis of the Acetabulum with Sequestrum, child, age two and one-half years. . IX 

221. Osteomyelitis of the Femur, child, age seven years IX 

222. Osteomyelitis near Hip-joint — Pneumococcus Infection, child, age three and one-half 

years IX 

223. Osteomyelitis near Hip-joint, child, age four and one-half years IX 

224. Mixed Infection of Hip-joint — Probable Osteomyelitis, girl, age six years IX 

225. Osteomyelitis of Lower End of Tibia, boy, age twelve years IX 

226. Osteomyelitis of the Lower End of the Right Femur, boy, age seven years IX 

227. Osteomyelitis of the Upper End of the Left Tibia, boy, age twelve years IX 

228. Early Stage of Osteomyelitis of the Lower Extremity of the Tibia, boy, age twelve years IX 



xviii ILLUSTRATIONS. 

PLATE DTV, 

229. Osteomyelitis of Fibula, girl, age eleven years IX 

230. Undetermined Infection of the Lower Epiphysis of the Tibia, boy, age ten years IX 

231. Chronic Infectious Osteomyelitis of the Upper End of the Tibia, boy, age six years. . . IX 

232. Atrophic Condition of Hands, boy, age twelve years IX 

233. Chronic Atrophic Condition of the Knee-joints, boy, age eight years IX 

234. An Infectious Arthritis of the Knee-joint — Chronic Atrophic Condition IX 

235. Syphilis of the Lower End of the Humerus, boy, age eleven years IX 

236. Syphilis of the Elbow and Forearm IX 

237. Syphilitic Dactylitis, child, age two years IX 

238. Syphilitic Periostitis, child, age five years IX 

239. Syphilitic Periostitis in Shaft of Tibia, boy, age eight years IX 

240. Syphilitic Osteoperiostitis and Osteochondritis, child, age six weeks. (La Fetra) .... IX 

241. Syphilis of Lower End of Tibia, girl, age twelve years IX 

242. Infection of Metatarsal Bone, girl, age twelve years. Tubercular Dactylitis, child, age 

three years IX 

243. Atrophy of Knee from Disuse, girl, age twelve years IX 

244. Tubercular Dactylitis, girl, age two and one-half years IX 

245. Tubercular Dactylitis, child, age three years IX 

246. Tuberculosis of the Lower Part of the Shaft of the Ulna, child, age three years IX 

247. Tuberculosis of the Carpal Bones, boy, age five years IX 

248. Tuberculosis in Elbow-joint, girl, age eight years IX 

249. Probable Mixed Infection of Hip-joint, child, age five years IX 

250. Tuberculosis of the Femur and Acetabulum, boy, age twelve years IX 

251. Mixed Infection of the Hip-joint and Acetabulum, child, age five years IX 

252. The End Result of an Old Tubercular Process, child, age fourteen years IX 

253. Probable Tubercular Infection of the Epiphyses, child, age eight years IX 

254. An Infectious Process in the Neck of the Femur, child, age five years IX 

255. Typical Tuberculosis of the Left Hip-joint — Marked Porosity of the Left Side, girl, 

age eight years IX 

256. Questionable Infection of the Knee-joint (probably Tuberculosis) — Infiltration of the 

Tissues, boy, age five years IX 

257. Typical Tuberculosis of the Knee-joint, boy, age eight years IX 

258. Abscess of the Thigh, boy, age six years IX 

259. Tuberculosis of the Epiphysis of the Tibia, child, age nine years IX 

260. Tuberculosis of the Os Calcis, child, age two and one-half years IX 

261. Tubercular Infection of the Epiphysis and Astragalus, child, age four years IX 

262. Tuberculosis of the Epiphysis of the Tibia, child, age five years IX 

263. Acute Tubercular Infection of the Os Calcis, boy, age twelve years IX 

264. Non-tubercular Infection about the Neck of the Femur, child, age five years '. IX 



ILLUSTRATIONS 

(ARRANGED ACCORDING TO THE AGE OF THE SUBJECT.) 



FIRST YEAR. 

PLATE DIV. 

Premature Infant, seven months 2 I 

Normal Head, age ten days 3 I 

Normal Trunk and Legs, age ten days 4 I 

Hour-glass Contraction of Stomach, infant, age five weeks 139 VII 

Hour-glass Contraction of Stomach — Tube in Stomach, infant, age five weeks 140 VII 

Syphilitic Osteoperiostitis and Osteochondritis, child, age six weeks (La Fetra) .... 240 IX 

Webbed Fingers, child, age two months 50 III 

Infantile Scorbutus, infant, age two months 80 IV 

Normal Head, infant, age ten weeks 5 I 

Normal Pelvis, Leg and Foot, infant, age ten weeks 6 I 

Normal Hand, infant, age three months 7 I 

Normal Thorax, Shoulders and Elbows, infant, age three months 8 I 

Obstetrical Paralysis of Right Shoulder, girl, age four months 73 III 

Normal Infant, age six months 9 I 

Normal Hand, Group A, girl, age six months 28 II 

Congenital Elevation of Right Scapula, infant, age six months 49 III 

Congenital Delayed Development of Right Leg, infant, age six months (Morse) 57 III 

The feet of the same subject as Plate 57, an infant, age six months 58 III 

Infantile Scorbutus, Organizing Clot and Haematoma of the Muscles, infant, age six 

months 78 IV 

Infantile Scorbutus, age six months 79 IV 

Malformation of the Radius and Ulna, infant, age eight months 52 III 

Acute Arthritis of Right Hip, child, age eight months 207 IX 

Infantile Scorbutus, Thickened Cortex and Periosteum, girl, age eleven months 76 IV 

Infantile Scorbutus, Subperiosteal, girl, age eleven months 77 IV 

Normal Thorax, child, age twelve months 10 I 

Anterior Poliomyelitis of the Left Shoulder, boy, age twelve months 168 IX 

Infantile Atrophy, infant, age twelve months 75 IV 

Incomplete Fracture of the Lower End of the Tibia, infant, age twelve months 192 IX 

SECOND YEAR. 

Epiphysitis of the Knee-joint, boy, age one year 198 IX 

Extra Digit, child, age one and one-half years 50 III 

Anterior Poliomyelitis of the Right Hand and Wrist, infant, age eighteen months. . . 167 IX 
An Anomalous Condition of the Second Metacarpal Bone, infant, age twenty-three 

months 62 III 

xix 



xx ILLUSTRATIONS. 

THIRD YEAR. 

PLATE DIV. 

Normal Infant, age two years 11 I 

Atrophy in Size of both Femora due to Paralysis of the Legs, infant, age two 

years 61 III 

Osteogenesis Imperfecta, Hand and Forearm, girl, age two years 68 III 

Osteogenesis Imperfecta, Leg-fractures, girl, age two years 69 III 

Early Rhachitis, child, age two years 82 IV 

Acute Osteomyelitis of the Right Femur, child, age two years 214 IX 

Chronic Osteomyelitis — Great Destruction of the Femur, child, age two years 215 IX 

Syphilitic Dactylitis, child, age two years 237 IX 

Osteogenesis Imperfecta, Leg-fractures, child, age twenty-five months 70 III 

Irregular Development, girl, age twenty-seven months 65 III 

Lobar Pneumonia, girl, twenty-seven months 115 VI 

Consolidation of Right Lung — Mongolian idiot, girl, age twenty-seven months 116 VI 

Lobar Pneumonia, girl, age twenty-seven months — Same subject as Plates 65, 115, 

and 116 117 VI 

Normal Hand, Group D, boy, age two and one-fourth years 31 II 

Osteomyelitis of the Acetabulum with Sequestrum, child, age two and one-half 

years 220 IX 

Syphilis of Elbow, girl, age two and one-half years 236 IX 

Tubercular Dactylitis, girl, age two and one-half years 244 IX 

Tuberculosis of the Os Calcis, child, age two and one-half years 260 IX 

Normal Hand, Group B, girl, age two and three-fourths years 29 II 

Normal Hand, Group C, girl, age two and three-fourths years 30 II 

FOURTH YEAR. 

Normal Infant, age three years 12 I 

Normal Knees, Lower Legs and Ankles, child, age three years 13 I 

Undeveloped Foot, child, age three years 56 III 

Early Rhachitis, child, age three years 81 TV 

Protuberant Abdomen, Knock-Knee, and Fiat-Foot, boy, age three years 87 IV 

Ethmoiditis, child, age three years 91 V 

Pneumococcus Lobar Pneumonia, girl, age three years Ill VI 

Early Miliary Tuberculosis of the Lungs, child, age three years 121 VI 

Emphysema, Gangrene, and Tuberculosis of the Left Lung, child, age three years. . 123 VI 

Complete Fracture of the Radius and Ulna, child, age three years 191 IX 

Infectious Arthritis — Atrophic Type, girl, age three years 200 IX 

Tubercular Dactylitis, child, age three years 242 IX 

Tubercular Dactylitis, child, age three years 245 IX 

Tuberculosis of the Lower Part of the Shaft of the Ulna, child, age three years 246 IX 

Osteomyelitis near Hip-joint — Pneumococcus Infection, child, age three and one-half 

years 222 IX 

Normal Hand, Group E, girl, age three and one-half years 32 II 

Spina Bifida Occulta, girl, age three and one-half years. Photograph 42 III 

Spina Bifida Occulta, a Roentgenograph of the same subject as Plates 42 and 44. . . 43 III 

Spina Bifida Occulta, a Roentgenograph of the same subject as Plates 42 and 43. . . 44 III 
Complete Fracture of the Lower Third of the Radius and Ulna with Impaction, child, 

age three to four years 190 IX 



ILLUSTRATIONS. xxi 
FIFTH YEAR. 

PLATE DIV. 

Fusion of Ribs — Marked Scoliosis of Congenital Origin, child, age four years 45 III 

Osteomyelitis of Vertebrae, girl, age four years 101 V 

Tuberculosis of the Spine, child, age four years 105 V 

Tuberculosis of the Spine. Same Subject as Plate 105 — Lateral View 106 V 

Unresolved Lobar Pneumonia, girl, age four years 114 VI 

Bronchopneumonia, child, age four years 118 VI 

Pneumonia — Inhalation of China Doll's Arm, girl, age four years 119 VI 

China Doll's Arm in Lung— Same Subject as Plates 119, 149, and 150 148 VIII 

China Doll's Arm in Lung — Same Subject as Plates 119, 148, and 150 149 VIII 

China Doll's Arm in Lung — Same Subject as Plates 119, 148, and 149 150 VIII 

Hook in the Larynx, child, age four years 146 VIII 

Anterior Poliomyelitis of the Left Arm, child, age four years 169 IX 

Impacted Fracture of the Surgical Neck of the Humerus, boy, age four years 183 IX 

Tubercular Infection of the Epiphysis and Astragalus, child, age four years 261 IX 

Syphilis of Forearm, girl, age four and one-fourth years 236 IX 

Giant-celled Sarcoma of the Thigh, boy, age four and one-half years 163 IX 

Infectious Arthritis of the Hand, boy, age four and one-half years 205 IX 

Osteomyelitis near Hip-joint, child, age four and one-half years 223 IX 

Retarded Development of Hand, boy, four years and nine months 63 III 

SIXTH YEAR. 

Normal Foot, child, age five years 14 I 

Foreign Body in Intestine, boy, age five years 144 VIII 

Multiple Exostoses of Tibia and Fibula, boy, age five years 172 IX 

Multiple Exostoses — Leg, boy, age five years 173 IX 

Dislocation of the Epiphysis of the Femur, boy, age five years 184 IX 

The Results of an Acute Destructive Process in the Hips, child, age five years 212 IX 

Syphilitic Periostitis, child, age five years 238 IX 

Tuberculosis of the Carpal Bones, boy, age five years 247 IX 

Probable Mixed Infection of the Hip-joint, child, age five years 249 IX 

Mixed Infection of the Hip-joint and Acetabulum, child, age five years 251 IX 

An Infectious Process in the Neck of the Femur, child, age five years 254 IX 

Questionable Infection of the Knee-joint (probably tuberculosis), boy, age five years 256 IX 

Tuberculosis of the Epiphysis of the Tibia, child, age five years 262 IX 

Non-tubercular Infection about the Neck of the Femur, child, age five years 264 IX 

Chondrodystrophia Fcetalis, girl, age five and one-half years 66 III 

^ Normal Hand, Group F, girl, age five and one-half years 33 II 

SEVENTH YEAR. 

Normal Child, age six years 15 I 

Normal Shoulder, child, age six years 16 I 

Normal Elbow, child, age six years 17 I 

Normal Knee, child, age six years 18 I 

Normal Thorax, child, age six years 19 I 

Normal Hand, Group H, child, age six years 35 II 

Anomaly of Upper Cervical Vertebras, boy, age six years 41 III 

Congenital Torticollis, boy, age six years 46 III 



xxii ILLUSTRATIONS. 

PLATE DIV. 

Congenital Elevation of Scapula. Left Side, boy, age six years 47 III 

Congenital Elevation of Right Scapula, boy, age six years 48 III 

Obstetrical Paralysis of the Left Arm — Marked Atrophy, boy, age six years 72 III 

Rhachitis of Spine, colored boy, age six years 100 V 

Thickened Pleura, boy, age six years 128 VI 

Collapsed Ribs, girl, age six years 130 VI 

Delayed Development of the Scaphoid, boy, age six years 159 IX 

Congestion of the Knee in a Case of Chronic Arthritis, child, age six years 197 IX 

Osteomyelitis of the Lower End of the Radius, boy, age six years 218 IX 

Mixed Infection of the Hip-joint, Probable Osteomyelitis, girl, age six years 224 IX 

Chronic Infectious Osteomyelitis of the Upper End of the Tibia, boy, age six years. 231 IX 

. Abscess of the Thigh, boy, age six years 258 IX 

Normal Hand, Group G, girl, age six and one-half years 34 II 

Normal Hand, Group I, girl, age six and three-fourths years 36 II 

EIGHTH YEAR 

Osteomalacia, girl, age seven years 74 IV 

Rhachitis, boy, age seven years. Photographs 83 IV 

Early Rhachitis — Thickened Cortex — Wolff's Law — boy, age seven years 84 IV 

Marked Rhachitis, boy, age seven years 86 IV 

Normal Thorax, girl, age seven years — Long Exposure. (Brown) 107 VI 

Normal Thorax, girl, age seven years — Short Exposure. (Brown) 108 VI 

Hydropneumothorax, boy, age seven years 125 VI 

Hydropneumothorax, boy, age seven years, the Same Subject as Plates 125 and 127 126 VI 

Osteomyelitis of the Femur, child, age seven years 221 IX 

Osteomyelitis of the Lower End of the Right Femur, boy, age seven years 226 IX 

NINTH YEAR. 

Congenital Deformity of Foot, boy, age eight years 54 III 

Myxcedema — Retarded Development — girl, age eight years 64 III 

Obstetrical Paralysis of the Left Arm, boy, age eight years 71 III 

Unerupted Permanent Teeth — Right Side of Head, boy, age eight years 95 V 

Pneumothorax, boy, age eight years. Same subject as Plates 125 and 126 127 VI 

Pleurisy with Effusion, child, age eight years 129 VI 

Retarded Development of Hand, boy, age eight years 157 IX 

Untreated but United Green-stick Fracture of the Tibia, boy, age eight years 185 IX 

Infectious Arthritis of the Shoulder-joint, girl, age eight years 203 IX 

Infectious Arthritis of Hands, girl, age eight years 204 IX 

Osteomyelitis of the Upper Shaft of the Tibia and of the Epiphysis, boy, age eight 

years 213 IX 

Typhoidal Osteomyelitis, child, age eight years 217 IX 

Chronic Atrophic Condition of the Knee-joints, boy, age eight years 233 IX 

An Infectious Arthritis of the Knee-joint, boy, age eight years 234 IX 

Syphilitic Periostitis of the Shaft of the Tibia, boy, age eight years 239 IX 

Tuberculosis of the Elbow-joint, girl, age eight years 248 IX 

Probable Tubercular Infection of the Epiphyses, child, age eight years 253 IX 

Typical Tuberculosis of the Left Hip- joint, girl, age eight years 255 IX 

Typical Tuberculosis of the Knee-joint, boy, age eight years 257 IX 

\ Normal Hand, Group J, girl, age eight and one-fourth years 37 II 



ILLUSTRATIONS. xxiii 
TENTH YEAR. 

^ TLATE DIV. 

Normal Hands, boy, age nine years 20 I 

Normal Abdomen, boy, age nine years. Short Exposure. (Brown) 137 VII 

Normal Abdomen, boy, age nine years. Long Exposure. (Brown) 138 VII 

Cellulitis of Tissues of Left Arm, boy, age nine years 161 IX 

Osteomyelitis of the Shaft of the Tibia, child, age nine years 210 IX 

Osteomyelitis of Elbow, boy, age nine years 216 IX 

Tuberculosis of the Epiphysis of the Tibia, child, age nine years 259 IX 

ELEVENTH YEAR. 

Normal Child, age ten years 21 I 

Normal Knees, Lower Legs and Foot, child, age ten years 22 I 

Normal Spine, child, age ten years 23 I 

Congenital Deformity of Hands and Arms, boy, age ten years 51 III 

Congenital Dislocation of the Radius and Ulna, boy, age ten years 53 III 

Congenital Dislocation of the Left Femur, boy, age ten years 60 III 

Advanced Rhachitis, boy, age ten years 85 IV 

Lobar Pneumonia, boy, age ten years 113 VI 

Acute Miliary Tuberculosis of the Lungs, boy, age ten years 120 VI 

Encapsulated Empyema, boy, age ten years 131 VI 

Dilated Heart, boy, age ten years 132 VI 

Periosteal Sarcoma — Lower End of Femur, boy, age ten years 165 IX 

Calluses of Feet, girl, age ten years 176 IX 

Abnormally High Arch of Foot, girl, age ten years 177 IX 

Intracapsular Fracture of the Femur, boy, age ten years 186 IX 

Dislocation of the Lower End of the Femur, boy, age ten years 187 IX 

Fracture of the Lower End of the Humerus with Inward Displacement of the Lower 

Fragment, boy, age ten years 188 IX 

Normal Foot, child, age ten years 195 IX 

Epiphysitis of the Upper Epiphysis of the Tibia, girl, age ten years 199 IX 

Effusion of the Knee-joint, boy, age ten years 206 IX 

Chronic Osteomyelitis of the Shaft of the Femur, child, age ten years 211 IX 

Undetermined Infection of the Lower Epiphysis of the Tibia, boy, age ten years .... 230 IX 

TWELFTH YEAR. 

Dislocation and Fracture of the Anatomic Head of the Humerus, boy, age eleven years 181 IX 

Fracture of the Astragalus, boy, age eleven years 193 IX 

Osteomyelitis of Fibula, girl, age eleven years 229 IX 

Syphilis of the Lower End of the Humerus, boy, age eleven years 235 IX 

Normal Hand, Group K, girl, age eleven and one-fourth years 38 II 

\Normal Hand, Group L, girl, age eleven and three-fourth years 39 II 

THIRTEENTH YEAR. 

Normal Child, age twelve years 24 I 

Normal Elbow, child, age twelve years 25 I 

Normal Thorax, child, age twelve years 26 I 

Rhachitis of Adolescence — Hand, child, age twelve years 89 IV 

Osteomyelitis of Lower Jaw, colored boy, age twelve years 92 V 

Enlarged Bronchial Nodes, girl, age twelve years 109 VI 



xxiv ILLUSTRATIONS. 

PLATE DIV. 

Double Pneumococcus Lobar Pneumonia, boy, age twelve years 112 VI 

Probable Old Tubercular Process of the Lung, child, age twelve years 122 VI 

Acute Miliary Tuberculosis of Both Lungs, girl, age twelve years 124 VI 

Pericardial Effusion, child, age twelve years 133 VT 

Enlarged Heart with Pericardial Effusion, child, age twelve years 134 VI 

Aneurism, boy, age twelve years 136 VI 

Abdominal Ascites, girl, age twelve years 141 VII 

Nail in Right Lung, boy, age twelve years 147 VIII 

Haematoma of Heel, child, age twelve years 162 IX 

Medullary Sarcoma of the Lower Part of the Femur, boy, age twelve years 164 IX 

Exostosis of Astragalus, boy, age twelve years 171 IX 

Exostosis of the Tibia, boy, age twelve years 175 IX 

Backward Displacement of the Inner Condyle of the Femur, boy, age twelve years . 179 IX 

Fracture of the Neck of the Humerus, boy, age twelve years 182 IX 

Green-stick Fracture of the Radius, girl, age twelve years 189 IX 

Fracture of Tibia with Compensatory Growth of Fibula, girl, age twelve years 196 IX 

Villous Arthritis, girl, age twelve years 201 IX 

Osteomyelitis of Lower End of Tibia, boy, age twelve years 225 IX 

Osteomyelitis of the Upper End of the Left Tibia, boy, age twelve years 227 IX 

Early Stage of Osteomyelitis of the Lower Extremity of the Tibia, boy, age twelve 

years 228 IX 

Atrophic Condition of Hands, boy, age twelve years 232 IX 

Syphilis of Lower End of Tibia, girl, age twelve years 241 IX 

Infection of Metatarsal Bone, girl, age twelve years 242 IX 

Atrophy of Knee from Disuse, girl, age twelve years 243 IX 

Tuberculosis of the Femur and Acetabulum, boy, age twelve years 250 IX 

Acute Tubercular Infection of the Os Calcis, boy, age twelve years 263 IX 

Double Congenital Dislocation of the Hip, girl, age twelve and one-half years 59 III 

FOURTEENTH YEAR. 

Right Side of Head, boy, age thirteen years 27 I 

Retarded Development of the Pisiform Bone and General Anomalous Condition, 

child, age thirteen years 67 III 

Rhachitis of Adolescence, Normal and Rhachitic Hands, boys, age thirteen years. . . 88 IV 

Fracture of Skull, boy, age thirteen years 90 V 

Anomalous Bicuspids, Left Side of Head, boy, age thirteen years 93 V 

Anomalous Lower Bicuspid, Right Side of Head, boy, age thirteen years 94 V 

Stone in Urethra, Encapsulating a Pin, girl, age thirteen years 143 VIII 

Premature Ossification of the Lower Epiphysis of the Radius, child, age thirteen years 158 IX 

Extreme Atrophy, boy, age thirteen years 166 IX 

Moderate Flat-foot, girl, age thirteen years 178 IX 

Ankylosis of Knee-joint, boy, age thirteen years 202 IX 

Normal Hand, Group M, girl, age thirteen and one-half years 40 II 

Chondrodystrophia Foetalis, boy, age thirteen and one-half years 66 III 

FIFTEENTH YEAR. 

Supernumerary Tooth, Right Side of Head, girl, age fourteen years 97 V 

Supernumerary Tooth, Left Side of Head, girl, age fourteen years 98 V 

The End Result of an Old Tubercular Process, child, age fourteen years 252 IX 



ILLUSTRATIONS. xxv 
SIXTEENTH YEAR. 

PLATB DIV. 

Supernumerary Tooth, Left Side of Head, boy, age thirteen years 96 V 

EXACT AGES UNKNOWN. 

Examples of Comparative Density Introduction 

Roentgenograph of a Congenital Deformity of the Foot 55 III 

Various Anomalous Conditions Connected with the Teeth (some of the ages are given 

in legend) 99 V 

Tuberculosis of the Spine, Ilium and Left Hip 102 V 

Tuberculosis of the Ilium 103 V 

Tubercular Abscess of the Spine 104 V 

Transposition of Organs — Tuberculosis of the Lungs and Bronchial Nodes 110 VI 

Pericardial Effusion and Obliteration of the Cardiohepatic Angle 135 VI 

Calcined Mesenteric Nodes 142 VII 

Foreign Body in (Esophagus 145 VIII 

Penny in the Descending Colon 151 VIII 

Needle in the Knee-joint 152 VIII 

Needle in the Knee-joint. Same subject as Plate 152, different position 153 VIII 

Needle in the Foot 154 VIII 

Needle in the Foot. Same subject as Plate 154, different position 155 VIII 

Needle in the Tissues Around the Phalanx of the Little Toe 156 VIII 

Early Ossification of the Upper Epiphysis of the Tibia 160 IX 

Subperiosteal Hemorrhage of the Left Leg 170 IX 

Exostosis of the Lower Part of the Femur 174 IX 

Fracture and Displacement of the Head of the Humerus 180 IX 

Old Fracture of Tibia and Fibula with Connecting Bridge 194 IX 

Rheumatic Fever — Knee-joint 208 IX 

Rheumatic Fever — Ankle-joint 209 IX 

Osteomyelitis of Lower Arm 219 IX 



LIVING ANATOMY AND 
PATHOLOGY 

THE DIAGNOSIS OF DISEASES 

IN 

EARLY LIFE 

BY THE 

ROENTGEN METHOD 



Introduction 

In a clinical text-book very little space should be given to de- 
scriptions of apparatus and to technic. These details should be 
acquired from books written for this purpose. The general principles 
should of course be understood, just as are the physics of ausculta- 
tion and percussion or the principles of the ophthalmoscope and 
of the electric battery. In using these methods of investigation we do 
not attempt to remember all the mechanical details, but begin at once 
to obtain clinical information from them. To read intelligently and 
understand what is shown to us by a Roentgenograph it is important 
that we should first have mastered a knowledge of the appear- 
ance of the gross anatomic and pathologic conditions as shown by 
post-mortem examinations. We can then use the knowledge ac- 
quired in this way to compare it with the same conditions as shown 
by the Roentgen method in the living subject. The purpose of this 
book is to teach exactly what is seen by the student when he examines 
a Roentgen plate or a print developed from it, and to depend on his 
own eye to interpret the conditions presented to him. In reading 
through another's eye the effort for original observation is diminished 
and the value of the knowledge thus obtained is reduced to the 
level of a diagram, being of about as much value for teaching as is 
a diagram in a book in comparison with what is taught to the student 



2 THE ROENTGEN RAY IN PEDIATRICS. 

by the use of the stethoscope. The difference in the methods of 
acquiring information on the one hand from hearing and touch and 
on the other from sight is that in the former case the expert instructor 
stands beside the student and educates his ear by telling him what 
he hears. On the contrary, by the Roentgen method the expert 
interpreter need not necessarily be present, but can be replaced by 
an expert explanation in a book, provided that such explanation 
describes accurately what the Roentgenograph shows. The personal 
element should in fact be eliminated as much as possible, because we 
all know how mistaken we may be and what different opinions are 
given in regard to what is heard and felt by different individuals. 
On the contrary, the eye does not err to the same extent. A number 
of pathologists do not differ so much in an opinion as to what they 
actually see in a liver at the postmortem as do a number of clinical 
experts as to what they hear in the lung or feel in the abdomen during 
life. This is because our senses of hearing and of touch are not con- 
stant, while, on the contrary, a photograph of the object is constant 
and gives reliable information. The Roentgenograph gives an actual 
picture of the lung, heart, and other organs ante mortem, just as 
the photograph of the liver, lung, or heart gives such accurate infor- 
mation post mortem. In either case the personal element is elimi- 
nated and the text can describe what a number of expert Roentgen- 
ologists can commonly agree to be present in the picture, just as a 
number of pathologists can agree in examining an organ at the 
autopsy. As to how much error occurs in and what can or cannot 
be seen in a special Roentgenograph will be explained later. It is 
fair to assume, however, always allowing that Roentgenology is in 
its infancy, and also that we cannot at present always read what is 
seen in the plate, that the picture as shown is true. Misconceptions 
may arise from a distortion of the angle at which the picture is taken, 
or from some faulty technic, or from lack of training in the interpre- 



INTRODUCTION. 3 

tation of what the eye is actually looking at. All these obstacles to a 
correct diagnosis will in the future gradually disappear as progress is 
made in perfecting the electrical machine and when practitioners be- 
come as expert in the use of the plate or Roentgenograph as they 
are now in the use of the laryngoscope and of the ophthalmoscope. 
In order to obtain the most exact knowledge of disease, every prac- 
titioner of medicine and surgery should be taught what the Roent- 
gen method is, and should have at his command pictures which can 
be readily explained. These explanations can be accomplished by a 
description in the text of the illustrations, aided by leaders desig- 
nating the important details. These if closely studied will make 
the diagnosis for the observer and will be of incalculable aid in 
treatment. 

Our knowledge of both the normal and pathologic anatomy of 
human beings has heretofore depended almost entirely on the post- 
mortem findings. These findings, although of great use, especially 
under abnormal conditions, have never been so complete as is desira- 
ble when the different stages of development are under consideration. 
Still greater difficulties arise when we attempt to determine the 
primary pathology of the various diseases. In many instances we are 
dealing only with results which may represent the terminal lesions 
of a number of diseases, and yet fail to give us the early and char- 
acteristic lesions of the especial disease. In other words, it is 
important to obtain an exact knowledge of the living pathology of 
the part affected from the time of the earliest deviation from the 
normal which it is possible to recognize, as the dead pathologic 
conditions may only give end results, and may be end results 
common to a number of different infections. Any means by 
which we may recognize a disease in its early stages, whether it 
be an effusion in the pericardium or in the pleura, or obscure 
centres of pulmonary solidification, or an osteomyelitis, or a clin- 



4 THE ROENTGEN RAY IN PEDIATRICS. 

ically hidden fracture, is of extreme value, and indeed a neces- 
sity according to our modern ideas of diagnosis for treatment. 
This means, more or less perfected, has been given to us by the 
Roentgen method, and the knowledge derived from this method, 
teaching us the actual living conditions, is becoming more and 
more extensive and exact. The constant study of children in health 
and in disease by the use of the Roentgen method will give us 
information of a large part of living normal and pathologic anatomy. 
This will enable us to judge of a diseased lung or other organ ante 
mortem, while prior to the discovery of the Roentgen ray we could 
only obtain our information from the findings of a post-mortem 
examination. It is therefore important that the results of the studies 
which have been made of a great variety of pathologic conditions 
by means of the Roentgen ray should be recorded and reported to 
the student of medicine in conjunction with his other medical studies. 
The Roentgen method in the practice of medicine assists rather than 
replaces any of the known means of diagnosis. It has opened up a 
new field in the study of health and of disease in both normal and 
pathologic conditions. It is not confined to the bones, but is 
applicable to all conditions of the tissues which from their histologic 
nature may be differentiated by the Roentgen ray. 

As is well known, there are two methods of obtaining informa- 
tion concerning the living normal and living pathologic conditions 
by means of the Roentgen ray. One is by the use of the fluoroscope 
and the other by the Roentgen plate. Each has its own advantages 
for diagnostic purposes. It is as useless, impractical, and narrow 
to praise one at the expense of the other, as it would be to discuss 
the individual merits of auscultation and percussion from the point 
of view that one should be used rather than the other. In one case, 
as in the other, it is the use of both methods which alone can give 
all the information ascertainable in health and in disease. There 



INTRODUCTION. 5 

is no doubt that the fluoroscope in the hands of an expert will give 
especially valuable information of the part examined. The expan- 
sion and contraction of the lungs, the rise and fall of the diaphragm, 
and the expansion and contraction of the muscles of the heart can 
by this method be actually seen and studied, as can also the peristalsis 
of the stomach and of the intestines. By this method we can deter- 
mine the normal excursions of the diaphragm as differing on one 
side from the other, and the greater or less distention of the lungs. 
We can thus also establish a standard which can be accepted as 
within the limits of normal variation according to the stage of devel- 
opment of the individual. In this way the trained eye is enabled 
to recognize the normal, to detect the abnormal, and to see the living 
rhythmic movements of the heart, the lungs, and the diaphragm. 
Bearing the normal standard in mind, and recognizing a greater or 
less excursion of the diaphragm, according to the greater or less 
expansion of the lung, we can decide whether we are looking at a 
normal or abnormal diaphragmatic excursion. If abnormal, and 
knowing that the lungs when over-distended show a greater radia- 
bility, and that when the pulmonary tissue is denser, or when the 
alveoli contain an exudate, they show a lessened radiability, we can 
infer that areas of disease are present. Also that in over-expansion 
we should suspect emphysema, while in deficient expansion we 
should infer a condition of atelectasis or of solidification. In this 
connection the use of the fluoroscope is of the greatest importance 
in the diagnosis of such conditions, as for instance an early tuber- 
culosis. The other side of the question in regard to the fluoroscopic 
method is that the sense of sight may vary, although not so much 
as does that of touch and of sound. Even experts may differ in an 
opinion as to what they see, just as experts in the use of the stetho- 
scope and pleximeter may differ as to what they hear or feel. It is 
also true that a good Roentgen plate tells the truth and records it 



6 THE ROENTGEN RAY IN PEDIATRICS. 

accurately. The plate may be poor and difficult to read, but if we 
grant a good fluoroscopic expert we must also grant an excellent 
plate. Such an expert, however, with the ever moving image of 
the picture, which he can simply describe and not record except in 
tracings made by his own hand, orthodiagraphic or otherwise, is 
invaluable on account of his skilled observation. The Roentgen 
plate and the record which it makes is absolute and can be 
referred to, studied, and discussed by any number of observers. 
There is no error in the plate due to a personal equation or to tem- 
perament. It can be studied as are photographs of the moon, which 
are far more valuable for exact rudimentary teaching than what 
can be seen through the telescope. When, moreover, the question 
arises of illustration in a book for the purpose of teaching the Roent- 
gen method, for the elucidation of diseases of all parts and organs, 
it is evident that the plate should be used. 

To take a Roentgenograph successfully a number of points are 
essential. A great deal depends upon the personality and knowledge 
of the operator and interpreter, and in the case of children on his 
patience and personal influence. The operator should have mechani- 
cal skill and great intelligence in making use of that skill. As an 
interpreter he should be as little as possible influenced by individual 
personality. He should also have an intimate knowledge of the 
pathologic conditions which have been studied and recognized as 
representing the various diseases as they appear post mortem. It 
is of course presupposed that he has also a thorough and detailed 
knowledge of the conditions which represent living normal anatomy 
at different periods of its development. In fact he should be both 
an anatomist and a pathologist. The degree to which pathologic 
conditions can be recognized in the Roentgenograph depends upon 
what can be demonstrated on the Roentgen plate. It is the grosser 
pathology which can be best recognized in the interpretation, 



INTRODUCTION. 7 

since the finer pathologic conditions shown by a microscope will 
not produce effects which can be differentiated by the eye. The 
Roentgen picture is obtained by the greater or less atomic weight 
of the tissue which the ray penetrates, as shown by the greater or 
less obstruction of the ray. For instance, if the radiability is 
great, as in the case of normal lung tissue, the dark surface of the 
plate is shown, while the neighboring vertebrae and ribs, owing to 
their increased density, obstruct the passage of the ray and are 
shown on the plate as white. When a print is taken from such a 
plate the reverse of this result takes place, the lung becoming light 
and the bone dark, and the right in the plate becoming the 
left in the print. What the student must remember, therefore, 
in considering the pictures on the plate, is that the greater the atomic 
weight of the object the greater is the density and the less the radia- 
bility; also that the nearer the object is brought to the plate the 
more precise and less distorted is the picture. Thus, to take the two 
extremes, if a cavity is filled with air the effect produced on the 
plate is practically nil, while if the cavity is filled with water the 
resulting picture is lighter according to the greater depth of the 
cavity. The student should therefore remember what radiability 
means, and appreciate that innumerable degrees of light or dark 
effects can be left on the plate corresponding to the innumerable 
degrees of density resulting from a difference in the atomic weights. 
When the student has mastered this idea he will learn to recognize 
first the radiability of normal tissue, for instance, what the picture 
of the normal lung with its great radiability should be, and then 
what is seen in a diseased lung when the radiability is decreased. 
Again, in reading the picture produced on the plate in abnormal 
conditions of the abdominal cavity, he must bear in mind that the 
greater the amount of fluid the less is the radiability and the lighter 
the resulting effect. He must also note the greatly lessened radiabil- 



8 THE ROENTGEN RAY IN PEDIATRICS. 

ity in the region of the liver, spleen, or kidney, and the abnormal size 
and density of the picture produced by an enlarged liver, spleen, 
kidney, or abnormal object such as a gall-stone, a renal calculus, 
or a foreign body. It should of course be understood that the 
picture on the plate may not necessarily be uniformly clear. On 
the other hand, a clear picture of a part may be obtained by skil- 
fully concentrating the ray on that part. It should also be under- 
stood that the print from the plate is never so clearly defined as 
is the original picture on the plate itself, even in the hands of one 
whose technic is excellent. It, therefore, becomes merely a question 
of improved technic and perfected reproduction. What we wish to 
teach the student is to cultivate his powers of observation and to 
recognize what the illustration shows. This can be done by means 
of leaders indicating the especial parts or details of the parts ex- 
plained in the text. It is evident that a very close and extended 
study of Roentgen plates in general should be made, in order to 
recognize the innumerable differences presented to the eye by a 
Roentgen illustration. 

The different tissues of the body are made up of different ele- 
ments, such as nitrogen, oxygen, calcium, phosphorus, and many 
others, each of which has its own atomic weight. We can therefore 
anticipate what the radiability of a given tissue, such as fat, muscle, 
and bone, will be, according as we know of what elements it is com- 
posed. Knowing the atomic weights of these elements we can then 
deduce that there will be a greater or less radiability. Thus where 
calcium is present, as in the bones, its high atomic weight (40) would 
produce a lessened radiability, while water, with its low atomic 
weight of hydrogen and oxygen, would allow of a high degree of 
radiability. Again, where much air is present in the medium through 
which the ray has to penetrate, the obstruction is almost nil. The 
radiability of air is so great that in the Roentgen plate there is a 



PLATE 1. 
EXAMPLES OF COMPARATIVE DENSITY. 

Fig. 1. Roentgenograph of the Shaft of a Long Bone. 

A. Cortex. 

B. Medulla. 

Fig. 2. The Diaphyses of a Tibia and a Fibula. 

A. Cortex of the tibia. 

B. Cortex of the fibula. 

C. Area of increased density from one bone over- 

lapping the other. 

Fig. 3. Diaphysis and Epiphysis of the Tibia and Fibula and 
the Superior Surface of the Astragalus. 

A. Diaphysis of the tibia. 

B. Diaphysis of the fibula. 

C. Zone of proliferation. 

D. Epiphysis of the tibia. 

E. Epiphysis of the fibula. 

F. Astragalus. 
H. Cartilage. 

/. Dark area from overlapping of the diaphyses of 

the tibia and of the fibula. 
J. Dark area from overlapping of the diaphysis of 

the fibula and the epiphysis of the tibia. 
K. Region of the capsule of the joint. 

Fig. 4. Heel of Foot. 

A. United epiphysis of os calcis. 

B. Fat. 

C. Space occupied by cartilage between os calcis and 

cuboid. 

D. Plantar fascia. 

Fig. 5. Comparison of Fat and Muscle. 

A. Fat. 

B. Muscle. 

Fig. 6. Comparison of Fat, Muscle, and Bone. 

A. Fat. 

B. Muscle. 

C. Outline of bone. 

(All these figures are taken from different plates.) 



FIG. 1 



Plate 1 




FIG. 2. 



FIG. 5. 





FIG. 3. 



K— ► 




FIG. 6. 




FIG. 4. 



>2 i < 

/^ B 
A 


: i 


► 



INTRODUCTION. 9 

very marked difference in the effect produced between, for instance, 
an emphysematous lung and an abdominal ascites. Of course, when 
tissues through which the ray passes have a low atomic weight, the 
radiability differs according to the number of layers of such tissues, 
or in other words the denser the tissue the less the radiability. The 
atomic weight of blood and that of water being so nearly alike, 
there is no great difference in their radiability. In order to explain 
diagrammatically what has just been said, I have shown in Plate 1 
the different degrees of radiability of different tissues and of the 
same tissue. 

Plate No. 9 (Div. I) shows the comparative radiability of the 
lung, heart, spine, liver, intestine, and stomach. 

The illustrations in Plates 1 and 9 emphasize that no one 
definite picture can be taken as a standard of one especial tissue, 
since the pictures of any of the tissues may differ considerably. 
This is shown in the difference of the radiability of the cancellous 
tissue in Plate 1, Figs. 2 and 3, leader A, and the muscle in Figs. 5 
and 6, leader B. All the reproductions in Plate 1 are taken from 
different prints. 

It must be understood therefore that the greater or less apparent 
radiability of an organ on one plate, for instance, of the effect pro- 
duced by a heart, may differ greatly from the apparent radiability 
of a heart on another plate, since the degree of radiability is 
determined by comparing it with the liver, lung, bones, and tissues 
on its own plate. Following from this the student must understand 
that there is no one especial degree of density which he is to expect 
to find in an individual plate. The radiability as shown in Plate 1 
represents what can be seen in a Roentgenograph, and in no way 
presupposes that the degree of density shown in these examples will 
always necessarily appear when the student is examining a plate for 
diagnosis. In other words, all the knowledge which is derived from 



10 THE ROENTGEN RAY IN PEDIATRICS. 

a Roentgen plate rests on a basis of comparison. The student must 
also understand when he is examining a print from a Roentgen plate 
that he should consider on which side of the part taken is the plate 
and that he is supposed to be looking through the plate at the part. 
He must, for instance, remember when he is looking at the trunk 
that he is looking at the individual from behind when the individual 
has his back on the plate. He must also remember, from our knowl- 
edge of the chemistry of the reproductive process, that, while the 
greater radiability of the lung tissue shows dark on the plate, it will 
show light on the print. In like manner, therefore, all light effects 
in the plate, such as of bone, heart, or liver, will show dark in the 
print. 

Like many other means for diagnosis where the technic is diffi- 
cult, discredit has been thrown upon the value of diagnosis by the 
Roentgen method. This discredit comes from a number of causes. 
First, the technic is difficult to acquire, and often has to be accom- 
plished by means of imperfect apparatus. Again, a systematic 
method of studying the plate, and thus interpreting what such a 
plate should show, is usually not employed. We must also under- 
stand that we often cannot expect to have as clear a picture in disease 
as in health. Given the same apparatus and the same skill in taking 
the pictures, the very indefiniteness of surface and of outline makes 
us suspect a diseased condition on comparing the picture with the 
same parts in their normal condition. In disease the greater or less 
atomic weight of the lungs and of fluids in the pericardium or pleura 
may throw a haziness over the whole picture and may obscure ana- 
tomic details which under normal conditions are very evident. This 
very haziness to the eye of the skilled interpreter becomes a definite 
entity and determines the diagnosis. 

Different Roentgenologists prefer different positions of the 
subject to be taken. The plate placed against the back or front 



INTRODUCTION. 11 

naturally produces pictures which, according to whether the parts 
are nearer or farther away from the plate, show more or less dis- 
tinctly. In taking the illustrations used in this book we have chosen 
for our routine position the subject's back directly against the plate. 
In this position we do not get the picture of the sternum and front 
of the ribs; these we take with the subject on the side, since pictures 
of the sternum taken with the subject on its face are unsatisfactory 
owing to the interposition of the vertebrse. Pictures which are 
taken with the back on the plate show what would be seen with the 
front part of the thorax removed, that is, the sternum, ribs, and 
cartilage about as far as the anterior axillary lines. 

It is the faulty technic in taking a Roentgenograph which 
invalidates accuracy, and a satisfactorjr interpretation is often lost 
by not approaching the subject in a systematic manner, such as we 
would use in making a physical examination of a patient. Before 
describing a uniform method for examining and interpreting the 
plate it is necessary to understand the difference between a photo- 
graph and a Roentgenograph. The photograph of an object shows 
in its negative only its exterior, which is reflected on the camera and 
on the eye, giving the outline, the shape, and the surface markings. 
In the Roentgenograph, the plate of which is positive, we do not see 
the exterior of the object, with the exception of its outline, shape, 
and prominences, but we get the details of its internal or general 
structure. Therefore in order to interpret Roentgenographs correctly 
it is necessary that we should not only be familiar with the external 
anatomy of the part to be examined but also with the interior struc- 
ture. In studying a given plate certain points must be considered 
and the same method followed as employed in the clinical diag- 
nosis of the lungs, pleura, and heart. In the examination of a Roent- 
genograph in reference to an extremity or to an organ, the general 
location, size, shape, and position should always be considered in 



12 THE ROENTGEN RAY IN PEDIATRICS. 

comparison with what is known of such part or parts. For instance, 
in an examination of the thorax a variation from the normal, such 
as a deficiency in the number of the ribs, or a variation in the number 
on one side in comparison with the other, should be noted. In exam- 
ining an extremity the general outline and the density of the part 
in question should be considered. Then we should study the picture 
as though a vertical section had been made through its tissues, and 
we should compare such section with the section of what would be 
normal at the same stage of development. For example, in examin- 
ing the Roentgenograph of a leg we should first compare the appear- 
ance of the fat tissue with what would normally be expected in the 
individual. We should next consider the muscle as to its atrophy 
or hypertrophy in comparison with normal muscle. Next we should 
observe whether the periosteum can be seen or not, knowing that 
under normal conditions it is not seen, and that if abnormal it 
may come into view. We next consider the cortical substance of 
the bone as to whether in comparison with the normal conditions 
of the cortex at the same period of development it is narrower, 
indicating atrophy, or broader, indicating hypertrophy. We should 
also note whether it shows increased radiability, indicating absorp- 
tion of the lime salts, or decreased radiability, showing thickening 
and greater density. Next we observe the medullary canal as 
to whether it is broader or narrower than under normal condi- 
tions, and also noticing whether it is replacing the cortex of the 
bone or, if it looks smaller, whether it is being encroached upon by 
an internal thickening of the surrounding cortex. All this is of im- 
portance in recognizing abnormal conditions, such as contusions, 
abscesses, atrophy due to nerve lesions or to general abnormal 
changes, such as growths or the presence of foreign bodies. 

A short resume of what has been stated already in regard to 
the detailed examination of a Roentgenograph may be of use to the 
student. 



INTRODUCTION. 13 

1. We should always compare the part of the individual under 
observation with the corresponding part of the same individual. 
This is often of great value where there may be only a slight devia- 
tion from the normal, as for instance in an arm from the normal 
arm on the other side. 

2. We should notice not only any change in the size but in the 
density, and any abnormal shape which may be present. 

3. Subcutaneous Tissue. — In examining the subcutaneous tissue 
we should note, in comparison with the corresponding opposite side, 
its density, its thickness, and its shape. 

4. Muscle. — In examining a muscle we should note any abnor- 
mality of outline, density, thickness, or shape, as denoting inflam- 
mation, abscess, foreign bodies, or new growths. 

5. Bone. — In examining a bone we should note the general 
outline, comparing the age of the individual under examination with 
what is known anatomically of a given part in regard to its age and 
size. We should also note whether the periosteum is visible or not, 
and whether there are any irregularities such as might be caused 
not only by changes in the periosteum but also by exostoses. By 
observation and experience, therefore, 

A. We should set a standard for ourselves as to the normal 

densities of the bones and of the tissues; 

B. We should then recognize a condition of atrophy, distin- 

guishing 

a. Atrophy from disease ; 

b. Atrophy from disuse; 

c. Atrophy from a combination of both. 

C. The size of the cortex and of the medullary canal and their 

relations to each other should be considered. 
Certain groups of diseases in early life, such as diseases of nutri- 
tion, are characterized by a diminution or an increase in surface and 
outline, and by a greater or less density of the bone. 



i [ THE ROENTGEN R w in PEDIATRICS, 

In examining for abnormal conditions of the COTtex we should 
note its density and its si/.e as compared with the medulla. The 
examination of a normal bono shows a uniform definition of the 
;c\. varying according to the density and siae o( the special part 
of the bone, but this again varies in different bones. For instance, 
the cortex of the femur at the upper end is thinner than the cortex at 
the middle of the shaft. A knowledge of the different variations in 
the si e of the cortex is important. It will not vary, however, to 
any great extent in different individuals. In certain diseases, such 
MS rhaehitis, osteomalacia, and osteogenesis imperfecta, the density 
of the cortex will vary from that of the normal to a greater or less 
extent. Thus from our knowledge of the normal cortex we w T ill be 
able to tell from the plate that there is a change in or a disease of 
the bone. It is important to compare the cortex with the medullary 
Banal, since in certain conditions it will be found that the medulla 
increases at the expense of the cortex, or that the cortex increases 
at the expense of the medulla. 

In examining the medullary canal we should note its density 
and compare it with the cortex, bearing in mind what should be 
normal in the individual stage of development present. The rnedul- 
larv canal can be demonstrated verv definitelv bv the Roentgen 
method. It varies in density and in width in the different bones 
and parts of bones, and here again is impressed upon us the impor- 
tance of knowing how each bone of the skeleton looks at different 
periods of development. This leads to the differentiation between 
atropi sue of the bone and atrophy from a change in its quality 

or from osteoporosis. 

We should also examine the stnictxtre of the bone, observing 
whether there is anything abnormal in connection with its cancellous 
ssoe or with its trabecule. It is in the differentiation of the differ- 
ent structures above mentioned that the Roentgen rav is able to 



IMTBODUCTIOH. 15 

detect disease. A knowledge o: the structure o: a giver. bone ::' the 
skeleton at different stages of its ieve: -.ill. in connection with 

the other points just mentioned, lead to an unders t anding of the 

early changes in a par: or in the whole :•: the hone. In :er::nn 
:tious processes e: the bone-marrow, where there is an inni- 
tration or an abscess, the normal structure :: the bone wih be seen to 
be destroyed or to be replaced by foreign no Again in iise 

such as rhachitis the structure of the bones will ~:;e seen :: 
itself to abnormal changes so as to compensate for the superincum- 
bent weight. 

6. Periosteum. — The periosteum in a normal bone is no: seen. 
and it becomes apparent only when there is an exudate benea:h in 
or when it is inflamed or thickened. 

7. Epiphyseal Line or Zone of Pre \ J . — We s' examine 
the epiphyseal line or zone of proliferation with great care. be:ause 
it is by a knowledge of its normal appearance that slight changes. 
such as from infection, from disturbance of nutrition, from trauma, 
from epiphyseal dislocations, from fractures. . ; from many changes 
that may affect its uniformity are revealed by the Roentgen method. 
Fractures should be looked for. whether parti::.! or complete. The 
attachment of the tendons, as represented by depressions ; : ::.- 
inences. should be noticed. Spur formation or hypertro] hi si - 
phytes should be recognized. No v t . o bon - oe par: 
show the same outline, but it is the knowledge of the normal and 
the variation from the normal which makes the interpretation of a 
slight degree of irregularity from disease possible. 

S. Epiphyses. — It should be noted whether the epiphyses of 
the various bones have appeared, their size, and their condition. 
9. The centres of ossification should be carefully n< 
We should always bear in mind that what would be normal for 
one period of development may be abnormal for another. Therefore 



16 THE ROENTGEN RAY IN PEDIATRICS. 

a knowledge of the different stages of development is of the 
greatest importance in determining whether 'disease is present or 
not. We must admit that we are studying histology and pathology 
in its most important aspect, that is, under living conditions, and 
that a knowledge of these conditions is exceedingly valuable not 
only for diagnosis but for treatment. We must remember that 
although the knowledge we obtain from the microscope is of very 
great value, yet at times macroscopic are as useful as micro- 
scopic pictures. A magnifying glass is of great use in studying 
reproductions from Roentgenographs. 



Division I 

LIVING NORMAL ANATOMY 

A thorough knowledge of living normal anatomic conditions 
should be acquired before we can understand what we see in living 
pathologic conditions and recognize the lesions of the various diseases 
during life. This would be comparatively simple if we could merely 
study the normal living anatomy of the fully developed adult, and 
of course such study is necessary and is very important. This living, 
fully developed anatomy of adults, however, is only one link of 
the much more extensive and complicated chain of evidence which 
enables us to diagnosticate normal anatomic conditions through 
all their stages of development in early life. During early life mani- 
fold changes take place continuously, and the younger the individual 
the more rapid are these changes. Therefore a knowledge of the 
living anatomy of each period of growth is of the utmost importance 
for the recognition of anomalies, of congenital conditions, and of 
disease. The study and use of the Roentgen method gives us a large 
part of the living anatomy and pathology of either an early or late 
period of disease, and thus enables us to decide upon the nature 
of the disease long before the findings of the post-mortem table 
can be utilized. Even anatomists know very little regarding the 
changes which take place in connection with the appearance and 
development of the centres of ossification at different ages, yet 
without this knowledge we cannot intelligently treat a number of 
diseases. 

During the development of the bones the epiphyseal line illus- 
trates the relationship of the diaphysis and epiphysis to each other 
and to their surrounding structures. From this it will be seen that 
the epiphyses present a very definite anatomic appearance at differ- 

2 17 



18 THE ROENTGEN RAY IN PEDIATRICS. 

ent periods. This not only occurs in the epiphyses of a special joint, 
such as the wrist, but in the epiphyses of the different joints as 
compared with each other. Thus the long bones have a large 
epiphysis at each end, while the clavicle, the metatarsal bones, 
and the phalanges of the foot and hand have only one. It is 
important to appreciate that the various epiphyses gradually appear 
and grow larger and larger according to the stage of development 
of the individual. An exact knowledge of their comparative develop- 
ment is therefore of great use. We know that height depends upon 
the development of the epiphyses. Suppose we are examining a 
child twelve years old who has the height of a child of six years, 
and we wish to determine what the chances are for his future increase 
in height; that is, whether he will eventually be a dwarf. On exam- 
ining the epiphyses, if we find that they correspond to the normal 
ossification of a child of twelve years, the probability is that the 
child will grow very little more in height. If, on the contrary, we 
find that the degree of ossification corresponds to the normal epiphy- 
seal development of six years, there is a chance that the growth in 
height may begin again. It is manifest, therefore, that unless we 
have this exact knowledge of the changes in even so small a part 
of the entire skeleton as the epiphyses, absolutely normal conditions 
may be mistaken for abnormal. This all the more emphasizes the 
importance of beginning our study of Roentgenology by acquiring a 
thorough knowledge of the normal living anatomy of the various 
stages of development. 

To obtain correct data of these normal anatomic conditions 
is not a simple question, since comparatively little aid is obtained 
from the many anatomists who have written on dead anatomic con- 
ditions. The fact is that the knowledge of normal living anatomy up 
to the present time has mostly depended upon what has been derived 
from dead anatomy. In addition to this the anatomist has relied 



LIVING NORMAL ANATOMY. 19 

greatly on the chronologic age of the individual whose dead anatomy 
he has investigated, and has stated from the results of his tabula- 
tions that a certain development takes place at a given age. We 
are now led to believe that this chronologic dead anatomy is far 
from correct, and that it does not approach the constant standard 
which we need in making an exact diagnosis of anatomic conditions 
in health and in disease. We are also more and more impressed, 
when our anatomic studies are carried out on the living subject by 
means of the Roentgen method, that the different stages of develop- 
ment must be readjusted and made to correspond to some other con- 
dition more constant than the chronologic one of age in months and 
years. By taking a Roentgen ray of a large number of apparently 
normal children in different stages of development, it has been shown 
that chronologic growth is far from exact for purposes of classifying 
children for school and athletics in comparison with the anatomic 
changes which take place from birth to pubescence. Crampton's 
work on the pubic hair in the latter period shows that there is a 
decided variation in the development of individuals of the same age. 
From some extensive work on this subject in which I have been 
engaged in the past two years, I have come to the conclusion that 
when we wish to determine the normal conditions of the various 
stages of life, some standard index, such as the changes in the epiphy- 
ses, is more reliable than the usually accepted standard of months 
and years. This work is fully described in Division II. I have 
deduced that, given an individual supposedly normal child, the 
wrist and hand are the most practical anatomic parts to use as a 
general standard index on which to establish a classification based 
on growth. From this reasoning I have concluded that if this hand 
and wrist standard of anatomic age proves to be superior in exact- 
ness to the chronologic age usually accepted, it will be of the greatest 
use in school life. In this way also a proper adjustment of athletic 



20 THE ROENTGEN RAY IN PEDIATRICS. 

contestants can be made by grouping the corresponding stages of 
development together anatomically rather than chronologically, 
thus avoiding overstrain at a period of life when it is of the utmost 
importance to do so. As much more work will be needed to definitely 
determine the shorter intervals of normal living development, I 
have provisionally grouped a number of chronologic periods together 
on an anatomic basis. The average periods of development deter- 
mined in the past by chronologic age, weight, or height, are mani- 
festly fallacious. We must make many observations based on a 
new system deduced from anatomic standards before healthy chil- 
dren can be classified according to what they, as individuals, need 
at certain periods of development rather than because they are of 
the same chronologic age. The exact meaning of this is that a group 
of children of the same chronologic age in months and years may 
represent perhaps four or five anatomic ages. 

In order to establish certain standards by which we can pro- 
visionally determine anatomic age in early life I have studied Roent- 
genographs of healthy children representing groups of chronologic 
age corresponding to anatomic conditions. To interpret intelli- 
gently living anatomic conditions as shown by the Roentgen ray 
it is necessary to be conversant with the anatomic conditions which 
have been revealed after death. The most important of these con- 
ditions is found in that part of the anatomy of the bones which shows 
the development of the epiphyses and of the diaphyses. Much valu- 
able knowledge can be acquired also from a careful comparative 
study of the organs and tissues, which is of great use in the differential 
diagnosis of various diseases by the ray. It is certainly very impor- 
tant that our knowledge of the centres of ossification of the bones at 
different periods of their development should be perfected. This 
can be accomplished best by studying the living normal anatomy 
of the bones by means of the Roentgen ray during life. In the series 



LIVING NORMAL ANATOMY. 21 

of normal anatomic pictures which I have introduced at the end of 
this division it should be noted that the centres of ossification are 
absent at first, then gradually appear as small plates, and finally 
assume their normal size. This series of cases starts with premature 
life and is carried on to adolescence. The determination of abnormal 
conditions of the lung and pleura, the degree of cardiac enlargement, 
and the question of pericardial effusion in the less obvious cases 
must also often rest on the evidence obtained by the Roentgen ray. 
This grouping by anatomic age is of importance surgically, 
because the surgeon when operating on an individual can by it 
often learn in what stage of development is the especial part on 
which he is operating. It is also of importance in medical cases to 
take into consideration the relation of the heart to the lungs, the 
relative size of each, and the different degrees of the cardiohepatic 
angle in its various stages of development. The practical use of 
the pictures of these groups of ages in surgery and in medicine is 
obvious. A surgeon is about to operate on an injury to a joint, or 
a physician wishes to determine where he shall operate in a 
pericardial effusion. Their procedure naturally would be to have 
a Roentgenograph taken of the especial case before them. They 
will then turn to the group of chronologic age or rather to the actual 
anatomic division of age which corresponds to the anatomic age of 
the individual whom they are about to treat. The Roentgenograph 
corresponding to the anatomic age of the especial child with which 
they are dealing will then show them whether at that especial period 
of life the appearance which they interpret from the special Roent- 
genograph of their patient corresponds to the general Roentgeno- 
graph of my normal anatomic series. If it does correspond they 
will decide that the picture of their case is that of a normal condition, 
and therefore that they should search further in order to find the 
real diseased condition. If, on the contrary, the picture of their 



22 THE ROENTGEN RAY IN PEDIATRICS. 

especial case does not correspond to such normal Roentgenograph, 
they will then judge that they are dealing either with a pathologic 
process or with an anomaly and that the case should be treated 
accordingly. In like manner in looking at the Roentgenograph 
which represents the heart it will be seen that the cardiohepatic 
angle is quite distinct, and that by the recognition of this angle on 
the right in a doubtful case of suspected pericardial effusion, the 
Roentgen ray would aid us very greatly in differentiating a normal 
or an enlarged heart from an effusion. 

Roentgenographs of the living normal development from the 
seventh to the ninth month of intra-uterine life show that there is 
comparatively little difference between these ages, with the excep- 
tion that the upper epiphysis of the tibia and the lower epiphysis 
of the femur appear at the latter date 

We can therefore adopt provisionally the period of growth 
from the seventh month of fetal life to birth as a group of anatomic 
growth, and call it Group 1 (Plate 2). This leads us to observe 
how long these early anatomic conditions continue, and thus for 
how long a period each group of normal anatomic conditions lasts. 

By following out this method of determination we can represent 
roughly different groups of anatomic age. Thus the second chrono- 
logic group can be represented by a period of life lasting from 
birth to the time when the first bones of the wrist appear in 
their cartilaginous surroundings. In like manner other groups 
may be classified until the whole period of childhood has been 
gone over up to the thirteenth or fourteenth year. There is much 
to be said in regard to these intervening periods of growth, and 
much practical use to which they may be put. I have thought, 
however, that it would be best first to show a number of illustra- 
tions of the child's development in different chronologic periods, 
then, in a division of the book by itself (Division II) , to show to what 



LIVING NORMAL ANATOMY. 23 

practical use this anatomic knowledge can be put in the every- 
day life of childhood. I have represented, therefore, in Division I 
in a general way certain periods of development of various parts 
of the entire body. I have begun with the premature infant (Plate 
2), and ended with Plates 26 and 27, which include about the 
twelfth, thirteenth, and fourteenth years, more or less. 

It is to be noticed that in a number of plates which represent 
otherwise the entire skeleton the heads do not appear. The reason 
for this is that it is extremely difficult to obtain a good Roentgeno- 
graph of the head of a young baby unless it is etherized. Under 
normal conditions it is seldom the case that the parents will allow 
the infant to be etherized for the purpose of scientific illustration. 
On the other hand, it is not difficult to obtain a Roentgenograph 
of the premature infant, since its breathing is very shallow and it 
often does not move its head for many minutes. 

The acute angle made by the right side of the heart with the 
upper surface of the liver is called the cardiohepatic angle. This is 
well shown in Plate 9. It is of great importance to observe this 
angle carefully, as later it will be of much value in differentiating 
between an enlarged heart and a pericardial effusion. We should 
also note the areas occupied by the heart, the liver, and the abdominal 
organs. 

After this preliminary outline, we can now appreciate why we 
should make a careful study of living normal anatomy first, and 
later acquire a knowledge of living abnormal anatomy. Having 
once mastered the details of these living normal conditions through 
all their changes of development from the very beginning of life, 
the diagnosis of disease becomes greatly simplified. 

In order to appreciate why the various parts of the bone differ 
in their radiability according to the constituents of which they are 
composed, I shall describe briefly the structure of the bones and 
their development. 



24 THE ROENTGEN RAY IN PEDIATRICS. 

BONE 

Bone is the hardest structure of the human body, but also 
possesses a certain degree of toughness and elasticity. Its color in 
a fresh state is pinkish-white externally and red within. On exami- 
nation of a section of bone we find two kinds of tissue, one of which 
forms the dense hard external covering and is called the cortex; 
the other, which forms the interior of the bone and consists of fibres 
and of lamellae which join and form a reticular structure, is called 
the cancellous. It is to the variations in the relative quantities of 
these tissues that the difference in weight and size of the different 
bones, and also of the different parts of the same bone, is due. 
The bones are permeated by blood-vessels and are surrounded by a 
fibrous membrane called the periosteum, by which the blood supply 
is carried to the cortex. The long bones have a cavity filled with 
marrow, and are lined with a vascular structure called the medullary 
membrane. 

Periosteum. — The periosteum normally adheres to the bone 
in nearly all parts, excepting its extremities, which in early life are 
cartilaginous. It is thick and vascular, and is incorporated at either 
end of the bone with the epiphyseal cartilage. 

The constituents of bone, according to Gray, are as follows: 

Organic matter Gelatin and blood-vessels 33.30 

' Phosphate of lime 51.04 

Carbonate of lime . . . = 11.30 

Inorganic and earthy matter ^ Fluoride of calcium 2.00 

Phosphate of magnesia 1.16 

_ Soda and chloride of sodium 1.20 

It is by the predominance of the inorganic constituents of the 
bone with their varying atomic weights that we are able by means 
of the Roentgen method to differentiate the various parts of the 
bone clearly. 

As it is easier and more practical to study a Roentgenograph 



LIVING NORMAL ANATOMY 25 

as a whole, and in order to appreciate all the advantages of this 
method, we should learn to look at the living anatomy of either 
head, thorax, abdomen, or limbs as a whole, and thus determine the 
dependence of one part on the other as representing the interdepend- 
ence of all the abnormal conditions present. Having once mastered 
the picture in broad perspective, the especial disease for which we 
are looking can in this way be better differentiated and intelligently 
studied. When we have done this it is evident that, in such abnormal 
conditions as can be portrayed by the Roentgen ray, the Roent- 
gen method is complete, rational, and satisfactory, and is therefore 
very important for the purpose of differential diagnosis. 

Diaphyses and Epiphyses. — The long bones have an epiphy- 
sis at each end, with the exception of the clavicle, metatarsal and 
metacarpal bones, and the phalanges of the hand and foot, which 
have only one. In a premature infant of seven months the long 
bones have no ossific centres representing the epiphyses (see Plate 
2). The epiphyses are the most important centres of the skeleton, 
for on them depends its future development, especially in infancy 
and childhood, and when these centres are impaired there result 
far-reaching influences in later life. A thorough knowledge of the 
different changes which take place in even these small areas is very 
important, for these centres are where disease may begin, from 
which disease may disseminate, and where it may lead to disastrous 
consequences by leaving its permanent marks. 

The following table gives the time of the appearance of the 
ossific centres of the epiphyses, and represents the results of our 
study at the Children's Hospital of a large number of children. 

It must, however, be remembered that most of these estimated 
figures depend upon dissections and in some cases are erroneous. 
Many of them have, however, been verified or corrected by our 
observations on living subjects. 



26 THE ROENTGEN RAY IN PEDIATRICS. 

Table 1. — Time op the Appearance op the Epiphyses. 
Clavicle 18 years. 

upper extremity. 

„ f upper epiphysis (head) 6 to 8 months. 

' I tuberosities 3d year. (2d to 3d year.) 

f capitellum 1st year. (2d to 3d year.) 

TT , . , . trochlea 10th year. 

Humerus, lower epiphysis -{ , , . , , n _,, , . n ,. J 

e r J external epicondyle 12th to 13th year. 

L internal epicondyle 5th year. 

Eadius, lower epiphysis 2d to 4th year. 

Radius, upper epiphysis « 5th year. 

TT1 f lower epiphysis 5th to 7th year. 

' X styloid process 4th year. 

Ulna, upper epiphysis 10th year. 

Carpus birth to 15th year. 1 

Metacarpus about third year. 

Phalanges (1st, 2d, and 3d rows successively) 3d to 4th year. 



Femur 



LOWER EXTREMITY. 

lower epiphysis 4 to 6 weeks before birth. 

upper epiphysis within 6 months. 

trochanter major 5th year. 

trochanter minor 12th to 14th year. 

Patella 2d to 3d year. 

., . f upper epiphysis 8th to 9th month of fetal life. 

I lower epiphysis 6 or 12 months to 2 years. 

_., , ( upper epiphysis 4th year. 

" X lower epiphysis 2d to 3d year. 

Tarsus 6th month of fetal life to 4th year. 1 

Metatarsus 3d to 8th year. 

Phalanges 4th to 7th year (page 31). 

Os innominatum 8th to 19th week of fetal life (page 32). 

*For development of individual bones see pages 27-32. 

Development of Bone. — In the fetus up to about the fourth 
month the osseous system represented by the long bones is more or 
less cartilaginous, while that part which is represented by the cranial 
bones is intramembranous. At the third or fourth month of fetal 
life the shafts of the bones show a cortex and a medullary cavity, 
but at birth no epiphyses excepting those above mentioned, such 
as of the femur and of the tibia, are present. 

There is also a third kind of ossification which is called sub- 
periosteal. 



LIVING NORMAL ANATOMY. 27 

As the long bones are the most important in the osseous system 
and are better understood than the others, I shall mention in brief 
the changes which they undergo in their development. During the 
first three months of intra-uterine life (this varying in the individual 
fetus) the osseous system is practically cartilaginous. Soon after 
this a process begins in the centre and extends towards the 
extremities. Subsequently a process begins here and there in the 
end of the bone and gradually extends. The epiphyses, however, 
do not join the shaft until growth has ceased, and they remain 
separated by a layer of cartilaginous tissue called the epiphyseal 
cartilage or zone of proliferation. Early in the process of ossification 
the cartilage cells of the centres of ossification enlarge and arrange 
themselves in rows, which gradually are separated by an increase 
in the matrix in which they are imbedded. A calcareous deposit 
now takes place in the matrix between the cells, which become 
further separated by columns of longitudinal calcified matrix, which 
gives a granular opaque appearance. Some of the matrix becomes 
calcified into transverse columns extending from one longitudinal 
column to another. In this way cartilaginous cells are enclosed in 
cavities of an oblong shape with walls of calcified matrix. These 
cavities are called primary areolae. 

Humerus. — The humerus usually develops by seven centres, 
but sometimes by eight: 

One for the shaft. One for the capitellum. 

One for the head. One for the trochlea. 

One for the tuberosities. One for each condyle. 

At the eighth week in fetal life the nucleus of the shaft appears, 
and at birth the whole shaft is practically ossified. The extremities, 
however, remain cartilaginous. The ossific centre first to appear 
after birth (normal) is the capitellum at about the first year. At 
the sixth month an ossific centre of the upper epiphysis of the hu- 



28 THE ROENTGEN RAY IN PEDIATRICS. 

merus appears at about the same time as the head of the femur. 
At the beginning of the third year a centre for the tuberosities appears. 
This ossification is sometimes, but rarely, by two centres. During 
the middle of the fifth year or later the centres for the head and 
tuberosity have united to form a single large epiphysis. The carti- 
lage, however, may persist and on examination with the Roentgen 
ray be confused with a fracture. The lower end of the humerus 
beside the capitellum has the ossific centre for the internal condyle 
at the fifth year. The external condyle appears about the twelfth 
to the thirteenth year. 

Radius. — The radius develops by three centres : 

One for the shaft (eighth to ninth week of fetal life) . 
One for each extremity. 
At birth the bone is well ossified, but at the beginning of the 
third year the ossific centre for the lower epiphysis may appear, 
and between the fifth and sixth year the ossific centres for the 
upper epiphysis appear. 

Ulna. — The ulna develops by three centres: 
One for the shaft (eighth week of fetal life). 
One for the lower epiphysis. 
One for the olecranon. 
At birth both extremities are cartilaginous. The lower epiphysis 
appears at about the fifth to the seventh year. Sometimes this 
epiphysis appears as two centres, later uniting to form one. At the 
tenth year, sometimes a little later, the epiphysis of the olecranon 
process (upper epiphysis of ulna) appears. 

Carpus. — The carpal bones develop commonly from a single 
centre, and are all cartilaginous at birth. The ossific centres under 
normal conditions usually appear in the following order : 

The os magnum and the unciform appear very soon after 
birth, the os magnum usually appearing first. 



LIVING NORMAL ANATOMY. 29 

The cuneiform, about the second or third year. 
The semilunar, about the fourth or fifth year. 
The trapezium, about the fifth year. 
The scaphoid, about the fifth to sixth year. 
The trapezoid, about the sixth to eighth year. 
The pisiform, about the twelfth year. 
According to Pryor the appearance of the trapezium, scaphoid, 
and trapezoid varies, and in his cases the trapezoid precedes the 
trapezium, but the scaphoid precedes the trapezoid. 

He has also found that at the same chronologic age the carpal 
bones of girls are in advance of those of boys, especially during 
the stage of pubescence. 

These observations of Pryor, however, do not invalidate the 
deductions on which my principle of developmental strength is 
based; for, as I look at the question, it is the number of carpal 
bones, rather than the order in which they come, which makes 
this strength. 

Metacarpus. — The metacarpal bones are developed from two 
centres : 

One for the shaft (sixth week of fetal life) . 
One for the epiphyses. 
The ossific centre of the epiphyses for the metacarpal bones 
appears about the third year, usually a little earlier. 
Phalanges. — The phalanges develop by two centres : 
One for the shaft (sixth week of fetal life) . 
One for the proximal ends. 
The ossific centres of the proximal ends appear at about the 
third year. 

Femur. — The femur is developed by five centres: 
One for the shaft. 
One for each extremity. 
One for the trochanters (greater and lesser) . 



30 THE ROENTGEN RAY IN PEDIATRICS. 

The ossific centre of the lower end of the shaft may appear 
about the end of the eighth month of fetal life, but usually in the 
early part of the ninth month. An infant at full term shows a well 
developed lower epiphysis. The lower epiphysis appears at about 
the ninth month of fetal life. The ossific centre for the head of the 
femur (upper epiphysis) appears usually within the first six months. 
The great trochanter is not seen definitely until the fifth year and 
joins the shaft at about the eighteenth year. The lesser trochanter 
appears from the twelfth to the fourteenth year and joins the shaft 
at the eighteenth year. It is to be noticed that the shaft and 
the diaphyses are rounded and smooth (Plate 18) presenting no 
sharp or ragged edges. This is an important point, as an early 
infection or a nutritional disturbance is first manifested by a ragged 
and irregular diaphysis. 

Patella. — The patella develops by a single centre. It has a 
density more definite than cartilage as a rule, but not so definite 
as bone. The tendon of the quadriceps extensor passing over the 
patella is continuous below with the fibres of the ligamentum patellae. 
The centre of ossification of the patella appears between the second 
and third year. The development of the patella is completed at 
about the thirteenth or fourteenth year. The bone sometimes, 
though rarely, develops from two centres placed side by side. It 
sometimes remains cartilaginous as late as the sixth year. 

Tibia. — The tibia develops by three centres, one for the shaft 
and one for each extremity. The ossific centre for the upper epiphy- 
sis of the tibia appears before birth, at the same relative time as the 
lower extremity of the femur, that is, at about the last of the eighth 
month or the first of the ninth month. The lower epiphysis appears 
soon after birth, usually about the middle to the last of the first 
year. 

Fibula. — The fibula is developed by three centres, one for the 
shaft (eighth week of fetal life?), and one for each extremity. The 



LIVING NORMAL ANATOMY. 31 

lower epiphysis appears first between the second and third year, 
and the upper epiphysis appears about the fourth year. 

Tarsus. — The tarsal bones develop by a single centre; they 
appear approximately as follows: 

Os calcis (sixth month of fetal life). This bone shows an 
irregular development from sometimes two or three 
centres of ossification. This normal condition must 
be carefully considered when some abnormality is 
being differentiated from a fracture. 
Astragalus (seventh month of fetal life). 
Cuboid (ninth month of fetal life). 
External cuneiform (first year) . 
Internal cuneiform (third year). 
Middle cuneiform (fourth year) . 
Scaphoid (fourth year) . 
The ossific centre for the epiphysis of the os calcis appears at 
the ninth year, and sometimes unites before puberty, but usually 
soon after. It at times develops from two centres. 

Metatarsus. — The metatarsal bones are developed from two 
centres : 

One for the shaft (ninth week of fetal life) . 

One for the distal extremities of the four outer metatarsal 

bones. 
One for the proximal end of the metatarsal bone of the 
great toe. 
The ossific centre of the proximal end of the epiphysis of the 
first metatarsal bone appears about the third year, while the centres 
of the distal epiphyses of the others appear about the fifth to eighth 
year. 

Phalanges. — The phalanges develop by two centres; 
One for the shaft (eighth week of fetal life). 
One for the proximal extremity. 



32 



THE ROENTGEN RAY IN PEDIATRICS. 



The ossific centre of the first row of phalanges appears at the 
fourth year, of the second row from the sixth to the seventh year, 
and of the third row in the ninth year. 

Os Innominatum. — The os innominatum develops by eight 
centres, three primary and five secondary : 

Crest of ilium. 

Anterior inferior spinous pro- 
cess (more common in 
the male). 

Tuberosity of the ischium. 

Symphysis pubis (more com- 
mon in the female). 

Acetabulum. 



Primary 



Ilium. 
Ischium. 
Os pubis. 



Secondary (each 
with one centre) 



These ossific centres appear in the following order : 

The ilium above the sciatic notch (eighth week of fetal life) . 
The body of the ischium (twelfth week of fetal life) . 
The body of the os pubis (sixteenth to nineteenth week of 
fetal life) . 
At birth the ilium, ischium, and os pubis are separated, the 
crests and the bottom of the acetabulum being cartilaginous. At 
the fourth year the rami of the ischium and pubis begin to grow 
toward each other, thus completing the obturator foramen. This 
occurs between the sixth, seventh, and eighth years. The cartilage 
of the acetabulum becomes ossified by the thirteenth year. The 
ischium and ilium unite at the age of puberty. 

TEETH 

The role which at the present time the teeth of children play 
in practical medicine is so great that a description of the normal 
teeth as preparatory to the study of abnormal conditions is quite 
necessary. 



LIVING NORMAL ANATOMY. 33 

Since the use of the Roentgen ray in dentistry has been estab- 
lished this role has become more and more extensive and important. 
No dental surgeon or odontologist is fully equipped unless he avails 
himself of the valuable addition to the instruments for diagnostic 
precision which we possess in this wonderfully accurate discovery 
of modern science. 

It is not my intention to go deeply into the subject of the 
teeth, or of the anomalies found in and about the jaws. I shall 
simply show that many conditions that heretofore have been seen 
only in the beautifully prepared specimens of the museums can now 
by means of the Roentgen method be studied during life. 

Enamel is formed from the epiblastic layer. In the same manner 
are formed the skin, the epithelium of the mouth, — except the tongue 
and the back part of the floor of the mouth, — and the appendages 
of the skin, such as the hair, nails, epithelium, glands, and nervous 
system. Dentine and cementum are formed from the mesoblastic 
layer. In this way also are formed the skeleton, muscular tissue, 
and connective tissue. Enamel is a substance composed of lime 
salts deposited by organic tissues which disappear during its forma- 
tion. The entire surface of the enamel is finely striated, the strise 
being transverse to the long axis of the crown. In addition to this 
fine striation there may be a few deeper and more pronounced grooves 
or pits which are pathologic and are marks of a check in develop- 
ment more or less complete. Two views have been held as to the 
formation of enamel. One is that it is formed by the actual conver- 
sion of the cells of the enamel organ into enamel. The other is that 
it is in some sense secreted or shed by these cells. In support of this 
latter theory there is the authority of well-known investigators, but 
some of the grounds on which their decisions are based are appear- 
ances which are open to a different interpretation. 

The deformities in the human teeth are found in the enamel 
3 



34 THE ROENTGEN RAY IN PEDIATRICS. 

and are due to checks in the development of or destruction of the 
ameloblasts. It becomes of great importance, therefore, that 
the causes of this check or destruction be anticipated as much 
as possible. 

Disturbances in the tissues formed from the epiblastic layer of 
cells in the embryo will in the new-born and up to the third or fourth 
year be likely to show their effects in the formation of the enamel 
of the permanent teeth. Such diseases as syphilis, tuberculosis, 
rhachitis, measles, and scarlet fever have long been considered as 
causes of these deformities, although it has been impossible in many 
cases where deformities exist to find any history of these diseases. 

The diseases of nutrition, while they may not cause deformities 
in the enamel, can so weaken the structure of the entire tooth that 
it may be impossible to preserve it. For this reason it should be 
understood how important it is to protect young children during 
the period of the first dentition from these infectious diseases and 
from the so-called diseases of nutrition. 

While we recognize the serious results which arise from disturb- 
ances of nutrition, those which arise from infectious diseases are 
not so commonly understood and accepted. 

For various reasons the laity are apt to say and to believe that 
it is well to allow the other children in a family where one child is 
infected, to be exposed to the disease. It is the duty of the physician 
under these circumstances to impress upon the parents that such 
grave secondary conditions as have just been described should be 
avoided. This is, of course, only one of the reasons for protesting 
against allowing a young child to be exposed unnecessarily to 
an infectious disease. 

In Table 2 and Table 3 I have indicated in a general way when 
the different groups of temporary and permanent teeth respectively 
are to be expected to erupt. 



LIVING NORMAL ANATOMY. 35 

There may be a variation of a number of weeks in the eruption 
of the various groups given in Table 2. 

Table 2.— Tempokary Teeth, First Dentition, 20 in Number. 
Dental Periods. Eruption of Groups of Teeth. Beginning of Calcification. 

I. 6 to 8 months 2 middle lower incisors. 



l. b to 8 montns 'Z middle lower incisors ) nA ,, , *,.-,•,., 

TT . n n , , , . . > 20th week of fetal life. 

II. 8 to 10 months 4 upper incisors J 

24th week of fetal life. 



III. 12 to 14 months 2 lateral lower incisors 

and 4 first molars. 

IV. 18 to 20 months 4 cuspids 

V. 24 to 30 months 4 second molars 



There may be a variation of a number of years in the eruption 
of the various groups given in Table 3. 

Table 3. — Permanent Teeth, Second Dentition, 32 in Number. 
Years. Groups. Beginning of Calcification. 

6 4 first molars 9th month of fetal life. 

7 4 middle incisors 



, 8 to 12 months of age. 
8 4 lateral incisors J 

9 4 first bicuspids 3 years. 

10 4 second bicuspids 4 years. 

11 4 cuspids 20th to 24th month. 

12 4 second molars 5 years. 

17 4 third molars 9 to 14 years. 

At the time of birth calcification of the entire crowns of the 
temporary central incisors and lateral incisors, and of about one- 
third of the cuspid teeth, usually takes place. About one-half of 
the first temporary molars, a little less than one-half of the second 
temporary molars, and the tips of the cusps of the first permanent 
molars also appear at this time (see Plate 3 and Plate 5). The 
calcification of the roots progresses until at about the eighteenth 
month when the apices of the temporary superior central incisors 
should be completely calcified. At the sixteenth month the apices 
of the temporary lateral incisors become calcified, and at about 
the twentieth month those of the first temporary molars. At the 
thirtieth month the apices of the temporary cuspids and those 
of the second temporary molars become calcined. These teeth 



36 THE ROENTGEN RAY IN PEDIATRICS. 

begin to erupt when about one-half of the root has become calcified. 
Tomes gives as stages of calcification at birth: "A full half of the 
length of the crown of the central incisor, about half that of the 
laterals, and the tip only of the cuspids. At birth the first temporary 
molars are complete as to their masticating surfaces. The second 
temporary molars have their cusps more or less irregularly united, 
in many cases the four cusps being united into a ring of dentine, 
the dentine in the central depression of the crown not being yet 
formed." 

Cases of deformity of the jaws or threatened deformity should 
be placed under treatment at an early age, in most instances before 
the temporary teeth have given place to the permanent ones. Room 
can thus be made for the misplaced or unerupted tooth to come into 
position where it will stay without long retention. If the Roentgen 
examination is resorted to at an early period much trouble will be 
saved for the child as well as for the orthodontist. 

(Plate 91, Division V, shows the normal temporary teeth in a 
child three years old.) 

During the period between the fourth and sixth years separation 
takes place between the temporary teeth anterior to the first tem- 
porary molar. This is due to the increased outward and forward 
development of the jaws, and also to the advancing permanent 
teeth which lie in the lingual aspect of the temporary cuspids and 
incisors. The bicuspids, which take the place of the temporary 
molars, lie directly above and below the latter, their crowns when 
in normal position being surrounded by the temporary molar roots. 
In many cases the second temporary molar is retained for quite a 
period of time, occupying more space than will be needed for the 
second bicuspid. Under certain conditions it may be necessary to 
extract, although the temporary molars are firm. Owing to the 
relation of the crowns of the bicuspids to the temporary molar roots, 



LIVING NORMAL ANATOMY. 37 

these partly developed permanent teeth may be sacrificed by the 
extraction of the temporary molars. This depends, however, upon 
whether the roots of the latter have reached a stage in absorption 
which will render them powerless to disturb the position of the under- 
lying teeth. The Roentgen examination is invaluable in these cases, 
for the unnecessary loss of one or more bicuspids may cause serious 
deformities. The calcification of the first permanent molar starts at 
the ninth month of fetal life (see Plate 3). 

On an average it is found that at the first year after birth the 
calcification of the tips of the central and lateral permanent incisors 
has taken place. In the second year one-sixth of the crowns of 
these teeth has been completed, and the tip of the cuspids. At 
the third year the tip of the first bicuspid has begun to calcify. At 
the fourth year about one-half of the central and lateral crowns, 
one-third of the cuspid crowns, and the tips of the second bicuspids 
have become calcified. Between the seventh and eighth year calcifi- 
cation has taken place in about one-half of the root of the central 
and lateral incisors, has just begun in the cuspid roots, and has just 
finished in the crowns of the bicuspids. The first permanent molar 
has kept just a little ahead of the central incisors in calcification, 
and at about the fourth year, when one-half of the central crown 
has become calcified, two-thirds of the crown of the first molar has. 
been completed. In the fifth year we find the crown of the first 
molar fully calcified, the central incisors almost so, and the tips of 
the cusps of the second molar just beginning. Plate 91 shows the 
stage of development of the first permanent molar in a child three 
years old. The average time for the development of this tooth is 
during the fifth year. 

At a given stage in the development of a tooth it is due to erupt, 
and if the question arises regarding its eruption, the Roentgen 
examination will determine whether from its development it is due 



38 THE ROENTGEN RAY IN PEDIATRICS. 

or overdue. If the picture indicates an abnormality, steps should 
be taken to correct it. If we are expecting a tooth to erupt, say the 
cuspid, any time between the ninth and fourteenth year, there are 
five intervening years in which serious trouble may occur. For 
instance, the tooth was due to erupt at nine years. From uncer- 
tainty the case might be allowed to progress with the result that 
through further development of the root and lack of space, it might 
be deflected from its course and later would have to be forced into 
its place. It is possible, also, that one or both lateral incisors may 
be missing. If these teeth do not erupt at the proper time it is wise 
to resort to the Roentgen examination in order to determine their 
position or absence. 

Plate 27 shows the normal development of the permanent 
teeth and the Roentgen method of determining whether a doubtful 
tooth belongs to the temporary or permanent groups. This plate 
shows very plainly all of the permanent teeth that should have 
erupted at this age in the upper jaw posterior to the cuspids. 

CHRONOLOGIC EXAMPLES OF NORMAL LIVING ANATOMY 

After these preliminary remarks on anatomic development, it 
will be useful to look at a number of plates of normal living anatomy 
in early life which I have arranged chronologically. The degrees 
of development shown, however, do not necessarily correspond in 
sequence to the chronologic ages. A careful inspection of these 
plates will demonstrate to the student the significance of the distinc- 
tion between chronologic age and anatomic growth which I shall 
fully explain in Division II, and the results of which seem to show 
that the child's well-being, in determining rules for its life, is best 
protected by relying on anatomic rather than on chronologic age. 

When the details of these normal living conditions through all 
their stages of development from the very beginning of life are 



LIVING NORMAL ANATOMY. 39 

mastered, the diagnosis of disease will be greatly simplified. We 
shall then be able to recognize in our search for a diseased condi- 
tion whether it is a stage of normal rather than abnormal develop- 
ment in the special individual whom we have before us. 

In the third month of intra-uterine life the skeleton of the 
fetus is practically completed. 

Plate 2 is that of a premature infant seven months old. 
The head of this infant, which was under my care at the Chil- 
dren's Hospital, shows quite a broad zone of increased radia- 
bility in both the frontal and upper parietal regions and in the 
occipital and postparietal, where there is an almost purely carti- 
laginous condition. The cranial bones at this stage of development 
show the condition of intramembranous ossification. All the sinuses 
are absent except the orbit, which is quite distinct, as is also 
the nasal cavity. Both the upper and lower jaws show indistinct 
pictures of the teeth in their cartilaginous surroundings, but the 
density is not sufficient to differentiate them. At the base of 
the skull is to be noticed the rudimentary atlas and axis and 
then the vertebral column through its whole length. Especially 
marked is the extreme radiability of the intravertebral disks in 
comparison with the lessened radiability of the bodies of the 
vertebrae, which, however, also show a cartilaginous condition of 
the transverse processes throughout the whole length of the spine. 
Starting from above it should be noted in comparison with the 
radiability in the cervical region the decreased radiability in the 
cardiac region, where the density of the heart is added to 
that of the spine. Between the ribs is seen the great radiability 
of the lung. The greater density of the liver is seen just below 
the lung, and below this again round light areas representing parts 
of the intestine. The pelvis is in a semi-cartilaginous condition. 
To be noted is the entire absence of bony structure in the front of 



40 THE ROENTGEN RAY IN PEDIATRICS. 

the pelvis, where the ilium, ischium, and os pubis are widely sepa- 
rated. All the long bones are developed, but no epiphyses are 
present in any of the joints. The clavicles are ossified. The humerus, 
the radius, the ulna, the femur, the tibia, and the fibula are repre- 
sented entirely by their diaphyses, which, however, are somewhat 
cartilaginous towards the ends at this age. No carpal bones are 
present at this stage of development, and no tarsal bones except the 
os calcis and the astragalus. To be noted also is the greater radia- 
bility of the central part of the tibia which shows the marrow light 
in comparison with the dark edges representing the cortex. The 
small size of the entire skeleton will be appreciated if we observe 
that the trunk in comparison with a moderate-sized safety-pin is 
only four times the length of the pin. 

Plate 3 represents the normal head of an infant aged ten 
days. The proportion of the face to the head at this age is very 
small. (For a further description of the face and cranium see 
" Pediatrics/ ' fifth edition, page 26.) The antrum shows no signs 
of development and does not appear until the eighth or the tenth 
month, except that it has gradually become a marked depression in 
the wall of the nasal cavity just at the time of the eruption of the 
first temporary teeth. The first temporary teeth are seen in their 
crypts partly calcified. 

In the upper jaw the incisors are indistinctly seen. 

The cusps of the temporary molars show the calcification which 
corresponds to a development of ten days. 

Plate 4 represents the thorax and upper legs of an infant ten 
days old. There is nothing especially noticeable about the thorax 
and abdomen to distinguish it from that of the fetus of nine months. 

The ilium, ischium, and os pubis are still ununited, and their 
cartilaginous separation still covers quite a broad area. 

While in the premature infant the lower epiphysis of the femur 



LIVING NORMAL ANATOMY. 41 

as seen in Plate 2 has not appeared, it has become quite distinct 
in this infant of ten days. 

Also to be noted in this infant, which is the same subject whose 
head has just been described, is the great radiability at the head of 
the femur, and that the cardiohepatic angle is clearly defined. 

To be noted in connection with these earlier stages of develop- 
ment is the picture of a normal stomach artificially dilated in an 
infant five weeks old (Division VII, Plate 140). 

Plate 5 shows the head of an infant ten weeks old. The 
first and second temporary molars show the degree of calcification 
which has taken place in their crowns. Anterior to the first tem- 
porary molar the teeth are indistinct and the picture is confused. 

Plate 6 shows a lower extremity of the same infant ten 
weeks old. To be especially noticed is the still undeveloped condi- 
tion of the bones of the pelvis. The lower epiphysis of the femur 
has become quite prominent, and this is also the case with the upper 
epiphysis of the tibia. The other epiphyses are not yet seen. The 
bones of the foot have increased in size and lessened in radiability 
in comparison with the same bones shown in Plate 2. They are 
the os calcis, the astragalus, and lower down the cuboid. 

Plate 7 shows the hand of an infant three months old. No 
epiphyses are present, and the only carpal bones that have appeared 
are the os magnum and the unciform. 

Plate 8 shows the normal thorax, humeri, and elbows of an 
infant from two to three months old. The only epiphysis present 
is the upper epiphysis of the humerus. 

Plate 9 shows the entire skeleton, excepting the head, of a 
girl six months old. To be especially noted are the cardiohepatic 
angle on the infant's right, the clearly defined outline of the stomach, 
and the presence of the lower epiphysis of the femur and the upper 
epiphysis of the tibia. There is no especial change in the spinal 



42 THE ROENTGEN RAY IN PEDIATRICS. 

column, except that the radiability in comparison with that in the 
plate of the earlier age just shown has gradually decreased. The out- 
line of the stomach is very clear at both the cardiac and pyloric 
extremities. The front of the pelvis is still in a cartilaginous condi- 
tion and is widely open. The shafts of the long bones are clearly 
marked. The cortex of the femur shows its lessened radiability in 
comparison with the radiability of the marrow. It is possible that the 
area marked B in the cardiac end of the stomach may represent the 
left kidney. The upper epiphysis of the humerus has appeared. No 
epiphysis has yet appeared at the lower end of the humerus. There 
are no epiphyses seen at the upper or at the lower ends of the radius 
and ulna. The bones of the carpus are very indistinct if seen at all, 
the os magnum and cuneiform bones possibly being shown in the 
midst of the irregular area to the left of the left wrist. Neither the 
upper nor the lower epiphysis of the fibula has yet appeared. The 
upper epiphysis of the tibia is present. On examining the tarsal 
bones it will be seen that not only the os calcis and the astragalus 
are present, but that the cuboid also seems to be present, while in 
the picture of the premature infant (Plate 2) the cuboid has not 
yet appeared. 

Plate 10 shows the normal trunk of a girl twelve months old. 
The different organs as described in the legend belonging to this 
plate are seen plainly. 

Plate 11 shows the skeleton of a girl about twenty-four months 
old. In this plate the transverse processes of the cervical vertebrae 
show a decreased radiability and are more ossified. The ribs show a 
greater density, and the stomach is not so clearly defined as in Plate 
9. The front of the pelvis is not so widely apart, ossification 
having apparently taken place in the ischium and ilium. The 
sacrum has become still less cartilaginous as shown by its lessened 
radiability. The shafts of the bones still show great radiability at 



LIVING NORMAL ANATOMY. 43 

their distal ends, but their cortex is distinct. The epiphysis of the 
upper end of the humerus has increased in size and shows lessened 
radiability as compared with the infant of six months. There is no 
epiphysis at the lower part of the humerus. A small epiphysis of 
considerable radiability is seen at the lower end of the radius. No 
epiphysis is seen at the lower end of the ulna. The carpal bones 
have now become much more distinct. The os magnum and the 
unciform are plainly in sight with their rapidly increasing density. 
Just behind the unciform bone is seen a minute highly radiable 
carpal bone, probably the cuneiform, although this bone is usually 
not supposed to appear until the third year. The metacarpal bones 
show the epiphyses. The epiphyses of the phalanges of the fingers 
are present. The epiphysis of the upper end of the femur has become 
much larger than seen in Plate 9 and shows decreased radiability. 
The epiphysis of the lower end of the femur has increased much in 
size, and the epiphyseal line is much decreased, its boundaries being 
smooth and regular. It is to be noticed that the trochanter major 
and trochanter minor have not yet appeared. The epiphysis of the 
upper end of the tibia has come plainly into view. The epiphysis 
of the upper end of the fibula is not yet seen, but is present at the 
lower end. The tarsal bones have much increased in size and show 
decreased radiability, the cuboid and external cuneiform apparently 
being absent. The metatarsal bones and the phalanges of the foot 
are too much massed to be differentiated. 

Plate 12 shows the skeleton of an infant about three and 
a half years old. In this plate there is no especial change in the 
density of the cervical vertebrae. The lumbar vertebrae are, however, 
unusually distinct and show decidedly lessened radiability in their 
bodies. There is somewhat greater radiability than is seen in the 
younger subjects already described. There is still no epiphysis at the 
upper end of the ulna or of the radius, but the epiphysis at the lower 



44 THE ROENTGEN RAY IN PEDIATRICS. 

end of the radius has increased in size. There is no epiphysis seen 
at the lower end of the ulna. The carpal bones have become more 
distinct and increased in size, being represented by the os mag- 
num, the unciform and the cuneiform bones. The epiphysis of 
the upper end of the humerus has increased in size. The capitellum 
is shown at the lower end of the humerus. The heads of the met- 
acarpal bones, the epiphysis of the metacarpal bone of the thumb, 
and the epiphyses of the proximal ends of the first phalanges are 
coming into view. The epiphysis of the upper end of the femur 
has become larger and the epiphyseal line narrower. The epiphyses 
of the lower end of the femur and of the upper end of the tibia 
have increased in size. The epiphysis of the lower end of the tibia 
shows increase in size and the epiphyseal line is narrower. The 
epiphysis of the lower end of the fibula is seen just behind the 
astragalus. The cuboid, external cuneiform, and internal cuneiform 
bones have become more prominent. No especial change is noticed 
in the metatarsal bones nor in the phalanges. 

Plate 13 shows the knees and lower limbs of a child three 
years old. 

Plate 14 shows the normal foot of a child five years old, which 
should be compared with the abnormal foot of a child three years 
old in Division III, Plate 56. 

Plate 15 shows the skeleton of a child about six years old. 
There is no especial change to be noted in the thorax of this child. 
The bodies of the transverse processes have become much more 
ossified and show greater density and lessened radiability. The 
ilium and ischium are closely approaching each other and are grad- 
ually completing the acetabulum. The processes of the ischium and 
of the os pubis have almost closed in so as to form the obturator 
foramen. The front of the pelvis is closing. The lower epiphysis 
of the ulna has begun to appear and is represented by two fine points. 



LIVING NORMAL ANATOMY. 45 

The lower epiphysis of the radius is gradually approaching its lower 
diaphysis. Starting with the os magnum, we see to the right the 
unciform and next to this the cuneiform, then the semilunar in the 
centre and just below the epiphysis of the radius, then the scaphoid, 
the trapezoid, and the trapezium. The four metacarpal bones show 
their epiphyses plainly. The first metacarpal bone (thumb) shows 
its epiphysis. The phalanges show their epiphyses plainly. The 
upper epiphysis of the femur is increasing in size. The greater tro- 
chanter appears very plainly and also the lesser trochanter. The 
lower epiphysis of the femur has become much more developed. 
The tarsal and metatarsal bones have become larger, but excepting 
the os calcis and the astragalus they are not clearly differentiated 
in the plate on account of a side view having been taken. 

Plate 16 shows the shoulder of a child six years old. 

Plate 17 shows the elbow of a child six years old. This is the 
same subject as Plate 16 and Plate 18. 

Plate 18 represents the knee of a child six years old, and is 
the same subject as Plate 16 and Plate 17. 

Plate 19 shows the normal thorax of a child six years old. 

Plate 20 shows the normal hands of a boy nine years old. 

Plate 21 shows the normal thorax, arm and hand, pelvis, 
and upper legs of a child ten years old. In this case the ray has 
been especially directed on the pelvis and hips, there being nothing 
special to be noted in the picture of the thorax. The sacrum is seen 
very plainly in the brim of the pelvis. The epiphysis of the upper 
end of the humerus is definitely developed, as are the external and 
internal condyles of the humerus, the epiphysis of the scapula, and 
the glenoid cavity. The upper epiphyses of the radius and of the 
ulna show plainly. The rami of the ischium and the os pubis have 
joined so as to form the obturator foramen. The ilium and the 
ischium have not yet joined. The epiphyseal line of the upper 



46 THE ROENTGEN RAY IN PEDIATRICS. 

epiphysis of the femur has become quite narrow and is smooth 
and even. Especially to be noted is the epiphysis of the greater 
trochanter. The epiphyseal line of the lower end of the radius is 
quite narrow, and the epiphysis of the lower end of the ulna is 
distinct. 

Plate 22 shows the knees, lower legs, and foot of the same 
subject. Especially to be noted are the well-developed epiphyses 
of the lower end of the femur and the upper end of the tibia with 
their narrow, clearly defined epiphyseal lines. The lower epiphysis 
of the tibia is present, and the upper and lower epiphyses of the 
fibula also are present. All the bones of the tarsus appear in this 
picture. Especially to be noted is the small pin-head development 
of the middle cuneiform and of the scaphoid: the latter is seen to 
have two centres of ossification. 

Plate 23 shows the normal spine of a child ten years old. 

Plate 24 shows the skeleton of a child twelve years old. All 
the epiphyses are well developed, and all the bones of the wrist 
are present. Note especially the pisiform bone overlying the 
unciform bone. The ilium and ischium have practically joined, 
forming the acetabulum. The os pubis is still open. The epiphyseal 
line of the greater trochanter has almost disappeared. The epiphysis 
of the os calcis with its narrow epiphyseal line is evident. All the 
carpal and tarsal bones are present. 

Plate 25 shows the normal elbow of a child of twelve years. 
The details of this plate are described in the legend. 

Plate 26 shows the normal thorax of a boy twelve years old. 
Especially to be noted is the epiphysis of the humerus, which is 
clearly defined and shows its union with the diaphysis well advanced. 
(The complete union occurs from the eighteenth to the twentieth 
year.) Note the decidedly lessened radiability of the heart and the 
sharply denned cardiohepatic angle. 



LIVING NORMAL ANATOMY. 47 

Plate 27 shows the head of a boy thirteen years old with a 
normal permanent set of teeth. This plate shows very plainly all 
of the permanent teeth that should have erupted at this age. In 
the upper jaw posterior to the cuspid the bicuspids are seen. The 
root of the second bicuspid and a small cavity can be seen in the 
floor of the antrum immediately above it. The first molar is 
in similar relation to the antrum, and small cavities can be seen 
in its floor over the anterior and posterior buccal roots. The 
second molar roots do not show so clearly. The third molar, only 
partly formed, can be plainly seen in its crypt. In the lower jaw 
the third molar can be seen with the distinct outline of its crypt 
and some calcification of its crown. The roots of the second molar 
are not yet formed. The crown of the first molar has been exten- 
sively filled, which accounts for the change in the density. The roots 
appear normal. The anterior root is not clearly shown, nor are the 
roots of the teeth anterior to the first molar, on account of the 
interposition of the teeth on the opposite side of the jaw. The object 
of this illustrative examination was to determine the nature of a 
tooth in the position of the first bicuspid. Here it is seen that the 
crown is much deformed, due to caries, in this case making it impos- 
sible to determine whether it was the first bicuspid or the first tem- 
porary molar, other indications pointing to the latter. The plate 
has not given us any assistance on this point, however, for a tooth 
extensively reconstructed on the other side of the jaw lies in the 
same field, destroying all faint outlines by its greater density. 

The doubtful tooth in question was again Roentgenographed 
by using a film inside the mouth, and the result is shown in the pic- 
ture at the bottom of the plate, so that it could be determined that 
it was the first bicuspid instead of a temporary molar. If it had 
been the first inferior temporary molar, it would have had four 
roots and would have shown two in the picture. The second root 
shown in the picture, however, declares the tooth's identity. 



PLATE 2. 
PREMATURE INFANT. 

7 months. (Reduced 58%.) 

A. Frontal and upper parietal region. 

B. Occipital and postparietal region. 

C. Orbit. 

D. Axis. 

X. Nasal cavity. 

E. Shows an anterior view of the third intervertebral cartilage. 

F. The arrow points toward the sixth vertebra. 

G. Heart. 
H. Lung. 

/. Coils of intestine. 

J. Cardiac end of stomach. 

K. Liver. 

L. Ramus of os pubis. 

M. Clavicles. 

N. Shaft of humerus. 

0. Shaft of radius. 

P. Shaft of ulna. 

Q. Shaft of femur. 

R. Shaft of tibia. 

S. Shaft of fibula. 

T. Os calcis. 

U. Astragalus. 

V, Phalanges of hand. 



Plate 2 




PLATE 3. 

Age 10 days. (Reduced 30%.) 

A. Area of increased density in occipital bone. 

B. Anterior fontanelle. 

C. Line of parietal and frontal sutures. 

D. Posterior fontanelle. 

F. Denser and lighter areas in occipital bone represent the 

tables. 

G. Beginning development of the frontal sinus. 
H. Orbit. 

I. Superior maxilla. 

J. Ethmoidal cells. 

K. Calcified cusps of first and second temporary molars. 

L. Crypt of first lower permanent molar. 



Plate 3 




PLATE 4. 
TRUNK AND LEGS. 

Age 10 days. (Reduced 46%.) 

A . Lower epiphysis of femur, at birth. 



Plate 4 







PLATE 5. 

Age 10 weeks. (Reduced 21§%.) 

A. Anterior fontanelle. 

B. Upper lateral incisor and temporary cuspid. 

C. Upper first temporary molar. 

D. Crypt of upper left first permanent molar. 

E. Crypt of lower left first permanent molar. 



PLATE 5 




PLATE 6. 
PELVIS— LEG— FOOT. 

Age 10 weeks. (Life size.) 

Normal development. 



Plate 6 






PLATE 7. 
NORMAL HAND 

Age 3 months. (Life size.) 



The os magnum and unciform bones have appeared, but no 
other bones of the hand and wrist are present. 



Plate 7 




PLATE 8. 
NORMAL THORAX, SHOULDERS, AND ELBOWS. 

Age 3 months. (Reduced 25%.) 



Plate 8 




PLATE 9. 
NORMAL INFANT. 

Age 6 months. (Reduced 65%.) 

A. Cardiohepatic angle. 

B. Stomach. 

C. Large intestine (ascending colon). 

D. Cortex of femur. 

E. Medulla of femur. 

F. Epiphysis of humerus. 

G. Clavicle. 
H. Carpus. 

I. Upper epiphysis of femur. 

J. Lower epiphysis of femur. 

K. Upper epiphysis of tibia. 

L. Tarsus. 

(By mistake in joining the two sections of the Roentgeno- 
graph they have not overlapped sufficiently, which gives the 
infant seven lumbar vertebra? instead of five.) 



Plate 9 






• 



PLATE 10. 
NORMAL THORAX. 

Age 12 months. (Reduced 24%.) 

A. Large intestine, descending. 

B. Large intestine, ascending. 

C. Liver. 

D. Lungs. 

E. Heart and spine. 

F. Cardiac end of stomach. 

G. Pyloric end of stomach. 



Plate 10 




■■^■^H 



PLATE 11. 

Age 2 years. (Reduced 70i% ) 

A. Upper epiphysis of humerus. 

B. Capitellum. 

C. Lower epiphysis of radius. 

D. Cuneiform. 

E. Epiphysis of head of femur. 

F. Epiphyses of tibia and fibula. 

The lower epiphysis of the femur and the upper epiphysis 
of the tibia are also shown. 



Plate 11 




c— s 



D 



/ 






^ 



; 



* a 




\ 




PLATE 12. 

Age 3 years. 

A. Ilium. 

B. Ischium. 

C. Os pubis. 

D. Obturator foramen. 

E. Capitellum. 

F. Lower epiphysis of fibula. 

G. Uncertain — possibly the trapezium, perhaps the scaphoid. 
H. Upper epiphysis of humerus. 



Plate 12 



y 




r 



\ 



•■»- 



m 






PLATE 13. 
NORMAL KNEES, LOWER LEGS,. AND ANKLES. 

Boy, 3 years of age. (Reduced 2Si%.) 

A. Lower cliaphysis of femur. 

B. Lower epiphysis of femur. 

C. Upper epiphysis of tibia. 

D. Foramen of nutrient artery of tibia. 

E. Cortex of tibia. 

F. Lower epiphysis of tibia. 

G. Lower epiphysis of fibula. 



Pi, ate 13 




PLATE 14. 
NORMAL FOOT. 

Child, age 5 years (Life size.) 

The structure of the bones is normal. 

The epiphyses of the tibia and fibula are present. 

The large tarsal bones are not yet massed. 

The epiphysis of the os calcis has not yet appeared. 

The cuboid corresponds to that of the normal at the fifth 
year. The group represented by the cuneiform bones is nor- 
mally developed, and the small scaphoid is seen just above this 
group and above the cuboid. 

The metatarsal and phalangeal bones are too much massed 
to be differentiated. 



Plate 1± 







PLATE 15. 

Age 6 years. (Reduced 63%.) 

A. Obturator foramen. 

B. Lower epiphysis of ulna. 

C. Os magnum. 

D. Cuneiform. 

E. Trapezoid. 

F. Region of greater trochanter. 

G. Region of lesser trochanter. 

Z. Epiphysis of fibula, partly beneath astragalus. 

1. Astragalus. 

2. Os calcis. 



Plate 15 








Ss 




x 




PLATE 16. 
NORMAL SHOULDER. 

Age 6 years. (Reduced 11|%.) (Same subject as Plates 17 and 18.) 

Especially to be noted is the fusion of the greater tuberosity 
with the head of the humerus. 



Plate 16 



k 












\ 




PLATE 17. 
NORMAL ELBOW. 

Age 6 years. (Life size.) (Same subject as Plates 16 and 18.) 

A. Shows the capitellum of the humerus. 



Plate 17 



PLATE 18. 
NORMAL KNEE. 

Age 6 years. (Life size.) (Same subject as Plates 16 and 17.) 

A. Points to upper epiphysis of the fibula. 



Plate 18 



PLATE 19. 
NORMAL THORAX. 

Age 6 years. (Reduced 45%.) 



Plate 19 




PLATE 20. 
NORMAL HANDS. 

Boy 9 years old. 



Plate 20 




PLATE 21. 
NORMAL CHILD. 

Age 10 years. (Reduced about 66% ) (Same subject as Plate 22.) 

A. Closed rami of pubes and ischium. 
B Upper epiphysis of femur. 
C. Greater trochanter. 



Plate 21 






PLATE 22. 
NORMAL KNEES, LOWER LEGS, AND FOOT. 

Age 10 years. (Reduced about 56%.) (Same subject as Plate 21.) 

D. Upper epiphysis of fibula. 

E. Two centres of ossification of scaphoid. 



Plate 22 





, 



D 



D 










* 




PLATE 23. 
NORMAL SPINE. 

Age 10 years. (Reduced 33|%.) 

Note the clearly defined details of the vertebrae. 



Plate 2'S 




g 







A*.iiL* 






PLATE 24. 

Age 12 years 

A. Pisiform bone. 

Note fairly defined epiphysis of external condyle. 




I/; 



In 






Pjlate 24 



i 





■ 




PLATE 25. 
NORMAL ELBOW. 

Age 12 years. (Reduced 24% ) 

A. Capitellum. 

B. Internal condyle. 

C. Epiphysis of upper end of ulna, — olecranon process. 

D. Upper epiphysis of radius. 



Pi, ate 25 




PLATE 26. 
NORMAL THORAX. 

Boy 12 years. (Reduced 50%.) 

Arms raised above head. 

A. Upper epiphysis of humerus. 

B. Cardiohepatic angle. 



Plate 26 




PLATE 27. 
RIGHT SIDE OF HEAD. 

Boy 13 years old. (Life size J 

A. Frontal sinus. 

B. Orbit. 

C. Sphenoidal sinus. 

D. Second upper bicuspid. 

E. Antrum. 

F. First upper molar. 

G. Third upper molar. 
H. Third lower molar. 

I. First lower bicuspid. 
7°. First lower bicuspid taken with film. 



Plate 27 



I D 



n 




tfih 



Division II 

ILLUSTRATIVE USE OF LIVING NORMAL ANATOMY 

The consideration of chronologic and anatomic age in early 
life has become very important, since the work of various investiga- 
tors, especially of Crampton, has shown the great discrepancy which 
exists between them. This discrepancy is not merely of scientific 
interest; on the contrary, it opens up a vast field for the study of 
the management of child life and for the change from existing customs 
in connection with it. 

Up to the present time the age of an individual has been com- 
puted by years, and this rule will probably always hold good from 
a legal point of view in all civilized communities. The question 
whether chronologic age is a wise division during the formative 
period of early life when brought to bear on our school systems, 
whether in classifying and grading children as to their studies, or 
pitting them against each other in athletic sports, becomes a very 
serious one. Again, when the important question of child-labor ig 
brought before us and we have to determine at what age a child 
should be allowed to work, we can at once see that a chronologic 
division for this purpose is not only insufficient but clearly perni- 
cious. It behooves us then to look at the question of age in early 
life: (1) from a chronologic point of view, — manifestly legal, — (2) as 
regards athletics, — manifestly anatomic, — (3) educational, as regards 
school grades, — manifestly a combination of chronologic, physiologic, 
and anatomic conditions. 

1. Legal chronologic age does not enter into this discussion. 

2. Anatomic age should first be carefully studied before school 
and child-labor can be dealt with intelligently. From a medical 
point of view the physiologic and anatomic conditions can for the 

4 49 



50 THE ROENTGEN RAY IN PEDIATRICS. 

present be considered as one, since at this point of the discussion we 
can consider the normal physiologic development of the various 
functions to correspond to and keep pace with the normal anatomic 
development. I wish it to be understood, however, that this supposi- 
tion is merely preliminary to some work which I expect to carry out 
later on this very subject, namely, whether it is true that deductions 
made from a physiologic standpoint can be properly used when 
compared with anatomic conditions. This will be a much more 
difficult investigation and probably will merely show that there 
is such correspondence between the physiology and the anatomy 
of human beings. This, however, should by no means be taken for 
granted and is still sub judice. The great importance of an exact 
knowledge of the anatomic development as expressed by the bones 
and joints to avoid overstrain at a time of life when this avoidance 
is of prime necessity should be impressed forcibly upon the public 
in general. This knowledge should be acquired especially by those 
who have charge of the athletic grading of boys and girls, whether 
in football or basketball or general gymnastics. Having determined 
what the anatomic growth is at different stages of development 
during the growing period, we can then apply this knowledge to the 
broad question of education and of child-labor. The problem at 
once presents itself as to the best method for determining the nor- 
mal anatomic development from birth to perhaps fourteen years, and 
how to express it in as small intervening periods as is possible and 
practical. This anatomic knowledge, however, should represent 
the different stages of living anatomy rather than depend on the 
results obtained from studying dead anatomic conditions. As our 
knowledge advances the anatomic intervals will become shorter 
and shorter. There is no doubt that from a somewhat extended 
study of the subject which I have made during the last two years 
a much closer and more reliable estimation of age from an anatomic 



ILLUSTRATIVE USE OF LIVING NORMAL ANATOMY. 51 

point of view can be made than could possibly be acquired from a 
chronologic. My belief is that in the future we shall determine age, 
whether for gymnastics, athletic sports, kindergarten, school, or 
child-labor, by means of anatomic conditions rather than by chrono- 
logic periods. It has been shown by a number of writers that growth 
is influenced by race and heredity and by social and hygienic condi- 
tions. Thus, for example, the Scandinavians, Scotch, and light- 
haired Germans are tall, while the Italians and French are short. 
The offspring of a mixed anatomic parentage is more like the large 
parent. The upper middle social stratum is most favorable for 
large growth, as is the upper middle hygienic stratum. It is known 
that at the period of pubescence the girl increases in growth more 
rapidly than does the boy, and that at or about the period of puberty 
the bones increase rapidly in length and in girth. As an instance of 
the unreliability of chronologic age can be cited the term puberty, 
a physiologic condition which is supposed to occur at a certain 
chronologic age. According to Crampton's admirable work on 
this subject, the age at which puberty in a group of children of the 
same chronologic age and of either sex is attained as expressed by 
years is fallacious, and indeed practically so variable as to amount 
to nothing. In a large number of healthy boys varying from ten 
to fifteen years the time of pubescence showed such a variation that 
Crampton claims that the growth of pubic hair indicates pubescence 
much more exactly and with far less differences of time than has 
been supposed to have been shown by stated years. In like manner 
Crampton has shown that the menstrual function of girls varies to 
a far greater extent in years than it does when reckoned by his 
physiologic sign of pubescence. Crampton also shows that such 
indications of growth as height, weight, appearance of teeth, and 
strength seem to correlate quite closely with the physiologic signs 
of pubescence. These indications, as individual factors of growth, 



52 THE ROENTGEN RAY IN PEDIATRICS. 

however, vary in the individual to such an extent that data taken 
from them for classifying children by years proves to be inadequate 
and indeed incorrect. Groups of boys of equal age and in the same 
grade in school, their grades being determined by their chronologic 
age, were found to vary perhaps by a year or a year and a half, not 
only in their height, weight, strength, and in the eruption of their 
permanent cuspids and second molars, but also in their being bright, 
moderately bright, or dull. With these results of Crampton before 
us, it is manifestly absurd to place children of the same chronologic 
age necessarily in the same grade at school. Therefore some more 
practical and closer data for classification should be sought for if 
the children are to be intelligently dealt with during their school 
years. Crampton's work and his deduction that the test of the 
growth of the pubic hair should be made use of in determining the 
real age of the child are based upon certain results which he claims 
show a much greater uniformity than does the division which has 
previously been made on the basis of years. Some of these results 
are as follows : 

Post-pubescents were found to average from 24 per cent, to 33 
per cent, heavier than pre-pubescents of the same age. Post-pubes- 
cents averaged as much as 11 per cent, taller than pre-pubescents 
of the same age. Post-pubescents averaged about 33 per cent, 
stronger than pre-pubescents. The higher the grade the fewer the 
pre-pubescents for age, hence post-pubescents are better in scholar- 
ship than pre-pubescents, and the more advanced a group is in 
pubescence the better will be the scholarship. Crampton also con- 
cluded that by far the greater part of the correlation of weight, 
height, and strength as found in scholarship m was due to the fact 
that they were all correlated in common with the pubescent factor. 
Crampton has also concluded that earlier pubescence favors good 
scholarship, later pubescence poor scholarship. In a study in regard 



ILLUSTRATIVE USE OF LIVING NORMAL ANATOMY. 53 

to the eruption of the teeth in about one thousand elementary school 
boys from ten to fifteen years of age it was found that the appear- 
ance of the teeth had but a slight relation to the actual chronologic 
age. It was also found that those boys who had a full set of per- 
manent cuspids averaged from five to seventeen pounds heavier, 
and from one inch to three inches taller than those with none. A 
preliminary study of weight, height, and strength showed that men- 
struees are taller, heavier, and stronger than non-menstruees, and 
that weight showed the closest correlation. These investigations 
of Crampton's have been based upon a period of years from nine 
to sixteen or seventeen, and on such physiologic data as could be 
deduced from observations during the pubescent period. Although 
certain investigators (Marro, " La Puberte") had already suggested 
that the growth of the axillary and of the pubic hair was significant as 
showing physiologic periods, yet such extensive investigations as 
Crampton's had not been carried out previous to his publications, 
and he was the first one to present the thesis that all our treatment 
of the child, whether educational, medical, or sociologic, should 
be based upon physiologic age rather than upon chronologic age. 
Deductions made from the observations of such external appearances 
as the pubic hair must necessarily not represent very short, and in 
that sense practical, intervals for the purposes of classification of 
which I have just spoken. It has therefore seemed to me, allowing 
for the present that a correlation of physiologic and anatomic condi- 
tions may be taken for granted, that a study of the anatomic condi- 
tions present from birth to thirteen or fourteen years may be of still 
greater value than the physiologic data based on the observation 
of the pubic hair. If such an anatomic classification can be made 
it will make no difference in its practical application whether the 
individual child is healthy or unhealthy, normal or abnormal, or is of 
one race or of another. It may be of a parentage differing in physical 



54 THE ROENTGEN RAY IN PEDIATRICS. 

development, excepting in so far as boys and girls can be separated 
normally in their anatomic development. That is, with such an 
anatomic classification we can practically work out our problems of 
child life irrespective of whether the individuals are boys or girls, 
and whether the girls menstruate early or late. This anatomic 
classification also is valuable for the purpose of adapting children 
from birth to adolescence to their proper healthy surroundings and 
to a life suited to their individual strength and capacity. In order 
to prepare for and clear the ground for the study of this question, 
namely, how to determine the normal condition of young human 
beings from birth to thirteen or fourteen years of age, certain pre- 
liminary investigations are necessary. 

With this end in view I have had over two hundred children, who 
according to our previous ideas should be considered normal in the 
different years of life, examined carefully. In order to obtain the 
required data the hygienic surroundings were investigated. It was 
noted whether the child was bright or dull mentally, what its general 
condition was with regard to its appearance, its various functions, and 
its appetite, and what diseases, if any, it had had previous to the 
time of its examination. Its age was noted; at what age it sat, 
stood, and walked alone, and a record of its weight and height made. 
If a girl, whether the catamenia had appeared; at what age, at what 
intervals, and with what regularity; also at what age the mammae 
began to develop and their present condition. The circumference 
of the head was noted, and also any information which could be 
obtained as to the closure of the fontanelle, and at what time the 
first dentition began; whether the temporary teeth had appeared 
at regular intervals; when the second dentition began, and whether 
it was being carried on regularly. A Roentgenograph was then 
taken of the carpal bones and the child was classified and placed 
in the division to which the bones of its wrist corresponded. Roent- 



ILLUSTRATIVE USE OF LIVING NORMAL ANATOMY. 55 

genographs were taken of those children only who were shown by 
examination to be presumably normal in their general development. 

This mass of data can be used for still further study of the 
correlation of weight, height, teeth, chronologic age, physiologic 
age, and various external evidences of normal development as shown 
in the records. It is my intention in the future to continue the 
study of early life on these lines in order to determine what correla- 
tion there is between all these different factors of the problem and 
the results which I have obtained from my investigations of anatomic 
age. As there can be but little doubt that normal physiologic age 
corresponds closely to normal anatomic age, it seems to me safe 
and warranted to assume that Crampton's physiologic investigations 
correlate closely with anatomic normal development. 

In undertaking to classify the different periods of early life on 
an anatomic basis, which will be of practical use in athletics, in 
school, and for questions relating to child-labor, it is evident that 
some reliable anatomic standard representing the entire physical 
development should be found. It is also important that such an 
anatomic standard should be readily obtained, and should be deter- 
mined in the living child with the least degree of complexity and 
in the most simple form possible. In the study of over a thousand 
cases of healthy children at the Children's Hospital by means of 
the Roentgen method our Roentgenologist, Dr. A. W. George, 
found that the most practical and reliable index of development 
was represented by the hand and wrist. It is true that various 
changes which progressively take place in the development of the 
shoulder, elbow, knee, and ankle are possibly somewhat finer than 
those of the wrist. For the purpose, however, of obtaining a practical 
and rapid knowledge of the progressive normal changes which take 
place at different periods of child life, the parts just enumerated 
do not compare with what can be accurately acquired in a few 



56 THE ROENTGEN RAY IN PEDIATRICS. 

seconds from the wrist and hand. It has occurred to me therefore 
that a careful study of the normal anatomic conditions present in 
the bones of the hand and wrist during different stages of their 
development would best aid us in classifying the different stages of 
development, and having formulated such a classification we could 
then apply it practically to physical and educational problems. 
During the last three years I have therefore had made careful studies 
of a large number of apparently healthy infants and children of 
different chronologic ages. A record has been kept of each of these 
children, not only as to their age, weight, height, teeth, general 
physiologic and anatomic condition, and social surroundings, but 
also a special record of the development of their hands, by means 
of the Roentgen method. As a result of these investigations it has 
been made very evident how unreliable are chronologic records in 
regard to weight, height, and teeth, the teeth especially showing the 
greatest variations. I shall not here, except in a general way, refer 
to the information which I have obtained regarding, for instance, 
the weight and height in reference to the chronologic age, since the 
unreliability of such correlation has often been shown by other 
investigators. I have, however, chosen for my classification only 
those individuals who by careful examination could be presumably 
considered normal. It must be understood that I am no longer 
dealing with stages of development as represented by years, but 
that my divisions are placed under letters. Having taken perhaps 
ten or a dozen children of each age chronologically I have then 
placed them under their respective anatomic stages of development, 
designating these stages by A, B, C, D, and so forth. I have then 
used these different stages for purposes of grading for kindergarten, 
for school, for athletics, and for child-labor. In a general way in 
making up these alphabetical groups I have arbitrarily assumed 
that the appearance of the carpal bones and of the lower epiphyses 



ILLUSTRATIVE USE OF LIVING NORMAL ANATOMY. 57 

of the radius and ulna should, according as they developed early 
or late, represent each alphabetical division. As none of these 
bones are normally present at birth, and as the os magnum and 
unciform bones appear in the first year, I have placed this group of 
cases under A. Under B I have grouped those hands which show 
the presence, in addition to Class A, of the lower epiphysis of the 
radius. Again under C, those which in common with A and B show 
the presence of the cuneiform bone. The heads of the metacarpal 
bones and the epiphyses of the first phalanges at this period can be 
used as controls of this latter group C. Still under these arbitrary 
divisions I have continued to place groups which successively show 
the presence of the semilunar and trapezium bones with the second 
and fourth phalangeal epiphyses as controls of this group. I 
have then introduced as additional groups those which show the 
scaphoid, the trapezoid, the lower epiphysis of the ulna, and the 
pisiform bones. These primary divisions are shown in Table 4 and 
this table can be used as a key by which we can show under which 
alphabetical division an especial case should be placed. This is 
accomplished by Roentgenographs showing a picture of such indi- 
vidual carpal bones and epiphyses. It is fortunate that the carpal 
bones and the lower epiphyses of the radius and of the ulna furnish 
a progressive series of anatomic development year by year, so that 
only in unusual cases will it be necessary to refer to the other epiphy- 
ses of the skeleton for the purpose of corroboration. 

Table 4. — Key to Index Development. Represents in Alphabetical Divisions 
the Developmental Stages of the First 14 Years of Life. 

A 

Plate 28 Girl, 6 months 

Os magnum and unciform bones. 

B 

Plate 29 Girl, 2$ years 

Os magnum, unciform, and lower epiphysis of radius. 



58 THE ROENTGEN RAY IN PEDIATRICS. 

C 

Plate 30 Girl, 2f years 

Os magnum, unciform, lower epiphysis of radius, cuneiform. 

D 

Plate 31 Boy, 2\ years 

Os magnum, unciform, lower epiphysis of radius, cuneiform, 

semilunar. 

Il 

Plate 32 Girl, 3£ years 

Os magnum, unciform, lower epiphysis of radius, cuneiform, 
semilunar, trapezium. (According to Pryor, scaphoid should 
come after semilunar.) 

F 

Plate 33 Girl, 5£ years 

Os magnum, unciform, lower epiphysis of radius, cuneiform, semi- 
lunar, trapezium, scaphoid. (According to Pryor, trapezoid 
should come after scaphoid.) 

G 

Plate 34 Girl, 6£ years 

Os magnum, unciform, lower epiphysis of radius, cuneiform, semi- 
lunar, trapezium, scaphoid, trapezoid. (According to Pryor, 
trapezium should come after trapezoid.) 

H 

Plate 35 Girl, 6 years 

Os magnum, unciform, lower epiphysis of radius, cuneiform, 
semilunar, trapezium, scaphoid, trapezoid, lower epiphysis of ulna. 

I 

Plate 36 Girl, 6f years 

Same number of bones as H but more developed. 

/ 

Plate 37 .Girl, 8\ years 

Same number of bones as I but more developed. 

K 

Plate 38 Girl, 11£ years 

Same number of bones as J, except that possibly the pisiform is 
beginning to show through the cuneiform. The carpal bones also 
are massing together closer than in J, which is significant of a 
more advanced development. 

Jb 

Plate 39 Girl, llf years 

Os magnum, unciform, lower epiphysis of radius, cuneiform, semi- 
lunar, trapezium, scaphoid, trapezoid, lower epiphysis of ulna. 
Pisiform seen coming out from under the cuneiform. 

M 

Plate 40 Boy, 13| years 

Same number of bones as L, but all the bones are larger and 
closer together, and the entire hand shows a much greater and 
later development than any of the other indices. Pisiform bone 
almost as large as cuneiform. _y 

In pursuing this investigation I have allowed for what appeared 
to be marked variations from the normal development. I have 
made my divisions irrespective of deviations, by grouping those 



ILLUSTRATIVE USE OF LIVING NORMAL ANATOMY. 59 

cases together which were manifestly in about the same stage of 
development in the large majority of cases. I am aware that the 
divisions which I have made may have to be subsequently changed 
according as further investigations are carried out in this line of 
study. In order, however, to formulate and start what I think in 
the future will be found to be of great aid in dealing with the early 
years of life, both anatomic and physiologic, it was necessary to 
begin by arbitrarily suggesting groups of classifications as they 
appeared to my eye to show uniformity. Some rather interesting 
observations in this connection have already come under my notice. 
For instance, hands may be long or short, broad or narrow, and yet 
the Roentgenograph will show that they may have the same degree 
of anatomic development, showing also that they should be classed 
together in one group. In making up such a group, however, we 
cannot be guided except to a limited degree by the external appear- 
ances of the hands. I have also noted in my study of these two 
hundred hands that although there may be a large hand, with large 
bones, as shown by the Roentgen picture, yet this does not 
necessarily imply advanced development, for the development of 
these large bones need not necessarily be great. I have noted 
also that the normal appearances shown in Roentgenographs of 
the hands of boys and girls do not materially differ, and that 
the left hand does not show any difference in development from 
the corresponding right hand. In all probability it will be found 
that many of the statements which have been made in the dif- 
ferent anatomies, which are the results of investigations on dead 
subjects, will be proved eventually to be incorrect when sub- 
mitted to the more exact observations which can be carried out 
on the living subject. Notably one of these discrepancies is that 
in a number of anatomies, English, French, and German, the lower 
epiphysis of the ulna has been placed as early as two and a half 



60 THE ROENTGEN RAY IN PEDIATRICS. 

years, three years, four years, and five years. The appearance of 
this epiphysis in my cases, however, was found to be very rare before 
the sixth year, and it usually began to appear in division H, where 
the children were from six to seven years old. It is also to be 
noted that while the pisiform bone has been found as early as the 
tenth year, and according to Porier, the eighth year, in none of my 
cases was it found before the twelfth year, excepting once as an 
anomaly in the eighth year. I have also noted that the heads of 
the metacarpal bones are not especially satisfactory, so far as classi- 
fication is concerned, and should therefore be used more as con- 
trols in cases where the development of the wrist is not sufficiently 
conclusive. 

In order to represent this classification practically we should 
have pictures which represent the development of the special group 
before us, and using these for comparison determine an individual 
child's anatomic age. These pictures I have prepared, choosing 
them as representative of their especial group. It is very evident, 
if this system of grading children in the future proves to be correct 
and useful, that, except legally, we should no longer think in years 
and months, but in normal anatomic groups A, B, C, and so on. 
We should remember also that all our physiologic knowledge should 
be brought to bear on this subject, using it in conjunction with, 
and as a control on, our anatomic knowledge; also that in doubtful 
cases the development of other parts of the skeleton, such as the 
shoulder, elbow, hip, knee, ankle, and foot, should be used as controls. 
We might indeed say that it is the sum total of all our physiologic 
knowledge, together with that of the development of the entire 
skeleton and the different organs, which tells us exactly how to 
solve the many problems of early life. For preliminary information, 
however, on these points we should first turn to what seems to be 
the most reliable index, namely, the wrist. These groups of course 



ILLUSTRATIVE USE OF LIVING NORMAL ANATOMY. 61 

are manifestly somewhat arbitrary, and depend upon my observa- 
tion of such cases as my experience has shown to represent the 
majority of normal conditions rather than variations. Further 
study may prove that it will be more exact to adopt certain other 
divisions and possibly to merge some of these present divisions into 
one. This, however, can easily be done if we are sure that the divi- 
sions are improved and made more practical in this way. What I 
wish to state, however, is that I believe we are working with the 
right principle, and that practical results in the line of perfecting 
the development of children and guarding them during the process 
of their development from overstrain both mentally and physically 
can thus be accomplished. It may be stated as a rule that, while 
in all probability weight and height correlate with a stated stage of 
normal anatomic development, that is, greater or less according to 
the anatomic development, yet this is true only where a group 
of individuals of the same anatomic development are concerned, 
rather than where the height and weight are compared with an 
individual of a stated chronologic age. It is very evident, as shown 
by those who have investigated the eruption of the teeth, that such 
eruption is entirely unreliable for purposes of classification. The 
sigma (range of variation) is very great as regards the eruption of 
the teeth and the height and the weight in comparison with the 
chronologic age, which in its turn shows a corresponding sigma as 
regards the anatomic conditions. 

The regulation of questions concerning the physical and mental 
care of the early years of life should be much more under the control 
of the medical profession than is now the case. An intimate knowl- 
edge of medical subjects and advanced medical training are needed 
to grasp these questions fully and to treat them intelligently. Surely 
it is one of the gravest duties of physicians to turn their attention 
to all subjects connected with children, and not to leave them to 



62 THE ROENTGEN RAY IN PEDIATRICS. 

be worked out by the non-professional laity. Educators dealing 
with these questions cannot accomplish what they are not by long 
years of physiologic and anatomic study fitted for. The educator 
in the public schools in grappling with the difficult questions of 
physical training should work hand in hand with the medical pro- 
fession, for thus only can the great end in view, of producing not 
only highly educated but healthy and vigorous citizens, be attained. 
The papers read in 1908 at the Delaware Water Gap by Abt, of 
Chicago, and by Kerley, of New York, on the vital questions con- 
nected with kindergarten and school life show the necessity for 
physicians, and especially for those who are interested in pedi- 
atrics, to take at once active measures to change the unwarrantable 
situation which confronts us in our schools and factories. This 
situation, with its irrational conditions and baneful results, is threat- 
ening to destroy the healthy bodies and minds of a large majority 
of our future citizens at the very beginning of their careers. It is 
giving them as preparatory for their race in life the handicap of a 
weak and easily strained physique and an overtaxed brain, at the 
very period of development when it tells most severely. I say this 
with a full understanding of how great is the recuperative power 
of the young. There are certain overstrains, however, which can 
never be eradicated, notwithstanding this high grade of recupera- 
tive power. At any rate we who have the knowledge and wisdom 
of adults have no right to subject millions of ignorant and helpless 
young human beings to a system of living which is disastrous to the 
majority. We also have no right in connection with this phase of 
life to trust to the survival of the fittest. On the contrary all these 
young lives should if possible be made to be the fittest. Such being 
our manifest duty, any means by which we can judge in the readiest 
way of the physical and mental conditions of the individual, and in 
this sense to care for and treat him personally according to his indi- 



ILLUSTRATIVE USE OF LIVING NORMAL ANATOMY. 63 

vidual needs, should be sought for. If it is decided that by the Roent- 
gen method applied to the hand, young human beings can be classified 
as individuals, it becomes a simple matter for the State or city by 
means of a Roentgen ray apparatus to rapidly make preliminary 
examinations. They can then classify physical conditions and the 
usually correlating brain vigor, for this can easily be done in an 
individual in less than a minute. In regard to the classification of 
young children for kindergarten, it is well known that in Massa- 
chusetts children may enter the kindergarten at from three and a 
half to five years of age and remain there for two years. They are 
then advanced to the first school grade, and thence through the suc- 
cessive grades to the ninth grade, from which they are graduated 
to the high school. Special localities have variations from this rule. 
In Melrose, for instance, children must be five years old before they 
are allowed to enter school. In the first year of their teaching they 
take partly kindergarten work and partly work of the first grade. 
The next year they take the work of the first and second grades, so 
that when they enter the third grade they have an equal standing 
with those of other third-year grades. By classifying young children 
according to their anatomic rather than to their chronologic age, 
we do away with the necessity for diverse rules. By grouping them 
according to their physical conditions we avoid the overstrain of 
both body and mind which arises from making them compete 
mentally with their stronger and more vigorous companions of 
equal chronologic age. This same method and this same idea should 
be carried out in the various school grades when a preliminary sifting 
and placing of the children is undertaken. To those who in reply 
to this would ask what is to be done with the precocious and bright 
children who are intellectually superior to their companions of 
equal chronologic age, I would say that I do not believe that bright 
children are dealt with as they should be or as is manifestly safe 



64 THE ROENTGEN RAY IN PEDIATRICS. 

for their future welfare. Both parents and teachers wish to stimulate 
these bright children in their studies and have them graded with 
groups of children who are older and are better fitted physically 
to undergo school life without overstrain. According to the physi- 
cian's point of view these children when they are found to be behind- 
hand in anatomic growth should not be allowed to be advanced on 
account of their mental brightness. They should be kept out of 
doors as much as possible, and special attention should be paid to 
their physical development until such development has shown the 
normal conditions requisite for health. As to the comparatively 
stupid children who present a normal or even more than normal 
physical development, as shown by the Roentgen examination, 
they should be allowed to find their level in the lower grades and, 
indeed, no great anxiety in regard to them is called for. In regard 
to gymnastics and athletics many a boy or girl could by careful 
anatomic grading be saved from the reactive debility which we so 
often see arise from an unwise overstrain of a physical handicap. 
Supposing we take twenty boys or girls at random, except that 
they are all ten years old chronologically. If we pit ten of these 
individuals against the other ten, either in football or in basketball, 
we are running the risk of pitting in a contest of strength ten individ- 
uals who may be only eight and a half or nine years old against ten 
who may be eleven or eleven and a half years old. Such a variation 
in chronologic age is found when we classify chronologically instead 
of using the anatomic standard which would pit ten against the 
other ten in such a way that the contestants would be of equal 
physique, which means equal anatomic age and the least likelihood 
of overstrain. 

Finally, in regard to the question of child-labor, it is certainly 
the duty of physicians to join hand in hand with educational, State, 
and city authorities to prevent children from being allowed to work, 
excepting under certain physical conditions. 



ILLUSTRATIVE USE OF LIVING NORMAL ANATOMY. 65 

I have already shown that a child may be, so far as chronologic 
age is concerned, of the age demanded by the law for child-labor, 
especially in factories. These laws of chronologic age differ in differ- 
ent States, and in some of the States there is not much to be found 
fault with in respect to the law. In others, however, the law permits 
children to begin work in the factories at entirely too early an age. 
I shall not discuss this question of child-labor very much in detail, 
as it is too broad a subject. There are, however, certain facts con- 
nected with the determination of the child's physical condition 
which should manifestly be referred to here. In the first place, 
we know that a child may be only eleven years old and yet look as 
though it were twelve or thirteen. In like manner, in my investiga- 
tions, I have found that a child may be thirteen years old and yet 
have only the normal anatomic development of eight years. This 
means that although it has the age of a child which would, according 
to the laws of certain States, allow it to work in the factories, yet, 
really, it is absolutely unfitted to do so. 

It may be said, of course, that these cases are rare. It is, how- 
ever, manifestly important to detect them when they present them- 
selves. That is, the individual should be examined to see whether 
physically and physiologically he or she is fitted for work in the 
factories or elsewhere, and not trust to chronologic age, which may 
differ by a year or a year and a half from anatomic age. 

It is not always the fault of those who employ children in the 
factories or elsewhere, as it often rests in the hands of the parents 
themselves. For instance, if a girl is tall and looks older than she 
really is, the parents are very apt to wish to make her earn wages 
for the support of the general household. Under these circum- 
stances, over and over again, they will say that the child is as old 
as she looks, and not tell the truth about her actual age. Again, 
often among the poorer classes in the South, the parents do not 

5 



66 THE ROENTGEN RAY IN PEDIATRICS. 

always know exactly how old the children are, as they may have 
forgotten. This not infrequently happens. How is the State law 
to be carried out justly when it is so handicapped by the ignorance 
and the lack of veracity of the parents, confirmed, under certain 
circumstances, by the outward appearance of the individual child? 
Manifestly, we should have some standard which does not depend 
upon veracity, intelligence, memory, greed, or external appearances. 
This can be accomplished by means of the Roentgen method, which 
always tells the truth, and is an open book to those who have learned 
to read its language. The simplicity of the method, merely to have 
a child for a second put its hand on a table and have it pictured by 
the Roentgen ray on a plate, without harm and without the slightest 
danger, must recommend it to all intelligent educators and to State 
officials. Physicians well know how important an aid to our medical 
armamentarium is the Roentgen method of examination. 

In the following table, No. 5, I have brought together some 
of the chronologic ages which I have extracted from the report of 
the Industrial Commission on Labor Legislation, Vol. V, Boston 
Public Library, 9331.073. 



Table 5.— State Laws Kegarding Child-labor. 

Nebraska * 
10 years. 



New Hampshire 
Vermont 
California 

In South Carolina if the parents are dependent children are allowed to work in 
the mills when they are 10 years old. 

Maine 

Khode Island 
Wisconsin 

12 years \ Maryland 

West Virginia 
North Dakota 
Tennessee 

- n . ... (New Jersey f 

12 to 14 years -> .. ' ' 

( Louisiana 

* Children under 12 years of age can work only 4 months in the year. 

t Girls, 12; boys, 14. 



14 years. 



ILLUSTRATIVE USE OF LIVING NORMAL ANATOMY. 67 

13 years i Pennsylvania 

\ Ohio 

Massachusetts 

Connecticut 

New York 

Indiana 

Illinois 

Michigan 

Missouri 

Minnesota 

Colorado 

Dist. of Columbia 

The employment of children under a certain age is absolutely 
forbidden in factories. The law also limits their employment in 
various forms of labor, with a view to their education in the public 
schools. It accomplishes this by restricting it unless they have 
certain educational qualifications, or by requiring licenses from the 
truant officers, factory inspectors, boards of health, or other persons 
before they can be employed in factories at all. 

Looking at this list of those who can endorse child-labor, we 
are at once struck with what an immense number of loop-holes 
may be present by which the law of the various States can be evaded. 

It is significant, however, in how many States the law is placed 
at twelve years, and still more in those which place it at ten. Prob- 
ably in some of the Southern States children are allowed to labor 
in the mills at a still earlier chronologic age. 

It would seem that the influence of the medical profession 
should be brought to bear more than it ever has before on this sub- 
ject. As a safeguard to the health of the children throughout the 
States, commissioners should be appointed who, by their training 
as physicians and caretakers of early life, can inform the State at 
what period of development it is safe to allow child-labor to begin. 

Of course a much further study of the carpal bones and of the 
epiphyses of the radius and of the ulna must be made before we 



68 THE ROENTGEN RAY IN PEDIATRICS. 

conclude what are to be considered and can be recognized as varia- 
tions or anomalies. This, however, I believe is possible if a number 
of Roentgenologists and physicians throughout the country pay 
attention to this anatomic question. Of course such physiologic 
observations as Crampton has placed before us will aid very much 
in the determination of anatomic age by means of the anatomic 
development of the wrist. 

In bringing before the medical profession this idea of using the 
Roentgen method for physical and mental classification, I wish it 
to be understood that I am merely asking it to endorse, and educators 
to make trial of, what seems a probable means of doing justice to 
young human beings. 

I have had to make arbitrary divisions, and these divisions 
should be studied and careful work of verification or refutation 
carried out on these lines. Such work, however, I believe to be 
worthy of trial, as if successful it simplifies the whole question of 
the guidance of child life, and wards off the dangers resulting from 
our present ill-advised management of the whole subject. 



PLATE 28. 
GROUP A. NORMAL. 

Girl, age 6 months. 

Os magnum and unciform bones are present; no epiphyses 
have developed. 



Pjlate 28 





PLATE 29. 
GROUP B. NORMAL. 

Girl, age 2| years. 

Os magnum, unciform, and lower epiphysis of radius. 

There are also present the epiphysis of the thumb (proxi- 
mal) and the epiphyses of the distal ends of the second, third, 
fourth, and fifth metacarpal bones; also the epiphyses (proxi- 
mal) of the first phalanges, and a very slight indication of the 
epiphysis of the distal phalanx of the thumb, and also a faint 
indication of the epiphysis (proximal) of the fourth phalanx. 
The other phalanges are obscured by the fingers of the attend- 
ant's hand which was restraining the infant's hand. 



Plate 29 





PLATE 30. 
GROUP C. NORMAL. 

Girl, age 2| years. 

The os magnum, unciform, lower epiphysis of radius and 
cuneiform are present. 

The epiphyses of all the metacarpal bones and of the pha- 
langes have appeared excepting the proximal epiphysis of the 
distal phalanx of the first finger and of the fifth. 



Pjlate 30 



V 



tt 



PLATE 31. 
GROUP D. NORMAL. 

Boy, age 2\ years. 

The os magnum, unciform, lower epiphysis of radius, cunei- 
form, and semilunar are present. 

All the epiphyses of the metacarpal bones and of the pha- 
langes have appeared excepting the distal phalanges of the first 
and fifth fingers. The proximal epiphyses of the metacarpal 
bones and first phalanx of the thumb are scarcely perceptible. 



Pjlate 31 



t> 




■' 




PLATE 32. 
GROUP E. NORMAL. 

Girl, age 3 J years. 

The os magnum, unciform, lower epiphysis of the radius, 
cuneiform, semilunar, and trapezium are present. 

All the epiphyses of the metacarpal bones and of the pha- 
langes are present. 

The arrowhead points at what is presumably the trapezium 
or the trapezoid, which with the scaphoid seem at times to be 
interchangeable. 



Plate 32 







PLATE 33. 
GROUP F. NORMAL. 

Girl, age 5i years. 

The os magnum, unciform, lower epiphysis of the radius, 
cuneiform, semilunar, trapezium, and scaphoid are present. 

A. Points to the trapezium or possibly according to Pryor to 

the trapezoid. 

B. Points to the scaphoid. 

All the epiphyses of the metacarpal bones and of the pha- 
langes are present. 



Plate 33 




B 



I 



PLATE 34. 
GROUP G. NORMAL. 

Girl, age 6J years. 

The os magnum, unciform, lower epiphysis of the radius, 
cuneiform, semilunar, trapezium, scaphoid, and trapezoid are 
present. 

All the epiphyses of the metacarpal bones and of the pha- 
langes are present. 



PliATE 34 



I 



111! 





PLATE 35. 
GROUP H. NORMAL. 

Girl, age 6 years. 

The os magnum, unciform, lower epiphysis of the radius ; 
cuneiform, semilunar, trapezium, scaphoid, trapezoid, and also 
the lower epiphysis of the ulna are present. 

All the epiphyses of the metacarpal bones and of the pha- 
langes are present. 

Note the beginning of the massing between the trapezium 
and trapezoid. 



Plate 35 




PLATE 36. 
GROUP I. NORMAL. 

Girl, age 6f years. 

Same as Group H as to number of bones, but much more 
advanced in development and more advanced as to massing. 



PliATE 36 




PLATE 37. 
GROUP J. NORMAL. 

Girl, age 8j years. 

Same as Group I, but more advanced in development. 



Pi, ate 37 




\\ 







/,>■• 



PLATE 38. 
GROUP K. NORMAL. 

Girl, age 11 \ years. 

Same as Group J, but the pisiform bone has appeared under 
the cuneiform, and all the carpal bones and epiphyses are much 
more massed and further advanced in development. 

Note marked advance in development of styloid process of 
lower epiphysis of the ulna. 



Plate 38 




PLATE 39. 
GROUP L. NORMAL. 

Girl, age llf years. 

Same as Group K. but more advanced in development. The 
pisiform bone appears plainly at the lower end of the cuneiform. 

The arrow points to the pisiform bone. 

Note the advanced development and the process of ossifica- 
tion beginning between the lower epiphyses of the radius and 
ulna with their diaphyses. 



Plate 39 




PLATE 40. 
GROUP M. NORMAL. 

Boy, age 13! years. 

Same as Group L, but very much more advanced in develop- 
ment, and the pisiform bone almost as much so as the cuneiform. 
The arrow points to the pisiform bone. 



Plate 40 







Division III 

DISEASES OF THE NEW-BORN 

By diseases of the new-born we mean such abnormal conditions 
as have occurred in intra-uterine life and are present at birth and 
in the early days of life. All these diseases, whether acquired in 
intra-uterine life or at the time of birth, depend in most cases on 
the great role which is played by development in its various stages. 
It is this developmental class which almost entirely represents the 
diseases of the new-born which can be shown by the Roentgen 
method of examination. It is well known that the growing tissues 
are more vulnerable and their power of resistance less when their 
complete development has not taken place. The tissues of early 
life are open not only to specific infections, but to numberless as 
yet undifferentiated varieties of pathogenic microorganisms which 
are but little understood. The effects, however, which these organ- 
isms have upon the normal growth of the various tissues and the 
abnormalities which may result from delayed or perverted normal 
anatomic conditions are recognized, and these conditions are shown 
in what are called malformations. The Roentgen examination of 
certain malformations of the mouth, nose, and extremities is of 
especial significance from a surgical point of view. Those of especial 
interest medically are malformations connected with the develop- 
ment of the teeth, heart, ribs, stomach, intestines, and liver. Under 
this class come also such conditions of arrested development as are 
represented in the bones where the transformation from cartilage 
to bone has either been arrested entirely or retarded to such an 
extent that marked shortening will always be present. The impor- 
tance of the study of diseases of the new-born has become more 
marked since the discovery of the Roentgen ray. In almost every 



70 THE ROENTGEN RAY IN PEDIATRICS. 

abnormal condition of this class we can by the Roentgen method 
determine the exact arrangement of the organs and bones, and in 
this way the underlying conditions of a given deformity can be 
made evident at once. By means of the Roentgen method of exami- 
nation the question of corrective measures and the prognosis in 
regard to future use are made possible. For purposes of simplicity 
these abnormal conditions can be classified into : 

Anomalies of the head, spine, and ribs. 
Intrathoracic and intra-abdominal diseases. 
Diseases of the extremities and pelvis. 
Chondrodystrophia foetalis. 
Osteogenesis imperfecta. 
Fetal rhachitis. 
Obstetrical paralysis. 

While the number of malformations in each of these divisions 
is large and represents definite abnormal conditions, yet those which 
can be portrayed, explained, and diagnosticated by the Roentgen 
method are comparatively small. New and heretofore unseen 
anomalies are met with from time to time, and to collect all the 
anomalous conditions which have been seen up to the present time 
would require a special work on this subject. I shall, therefore, 
only speak in a general way of diseases of the new-born in order to 
illustrate what great aid the Roentgen method of examination gives 
us by disclosing what the anomalous condition may be. If the dis- 
ease is surgically curable the picture shows us where and how best 
to operate. If it be of the class of cases which are represented by 
transposition of the organs, such as the heart in the thorax (see Divi- 
sion VI, Plate 110), or the liver and spleen in the abdomen, the 
knowledge of these conditions is of infinite aid. As the child grows 
older and its development increases, the Roentgen method assists in 



DISEASES OF THE NEW-BORN. 71 

the diagnosis of these diseases and proves that the condition is anom- 
alous and does not represent acquired disease. It is a fact that it 
is rare to find two identical anomalies in two individuals. It is to 
be clearly understood that the classification which I have just sug- 
gested is not based on any systematic division etiologically, patho- 
logically, or symptomatically, but is merely an attempt to bring before 
the student the pictures of the various parts in such a way that he 
can readily grasp their meaning. In studying a Roentgenograph of 
the entire skeleton we would naturally begin by examining the head, 
and then logically follow the picture down through the spine, thorax, 
and upper extremities, abdomen, pelvis, and lower extremities. 

ANOMALIES OF THE HEAD, SPINE, AND RIBS 
HEAD 

The anomalies of the head which can be distinguished at birth 
by the Roentgen ray and classified under diseases of the new-born 
are comparatively few in number. The variations and anomalies 
of the teeth would naturally be spoken of at a later period of develop- 
ment when the teeth, whether unerupted or erupted, play a more 
prominent role than is the case at birth. They will therefore be 
described in Division V under diseases of the head. 

SPINE 

Anomalous conditions of the vertebrae may occur in any part 
of the spine, as is seen in Plate 41, which shows the head and neck 
of a boy six years old with a congenital anomalous condition in the 
upper cervical region. There appears to be a fusion of the atlas 
with the base of the skull. The axis also shows marked deformity 
as compared with the normal upper cervical vertebrae shown in 
Plate 27. The remainder of the vertebrae seem to be normal. The 
child in this case shows a quite distinct normal orbit. The frontal 



72 THE ROENTGEN RAY IN PEDIATRICS. 

sinus does not show definitely. The antrum, as would be expected 
at this age, is small and ill-defined. In the upper jaw, beginning 
in front, we find all of the temporary teeth in place normally, but 
not clearly defined by individual markings up to the first temporary 
molar. This is due to the angle at which they were taken and to 
the consequent interference of the pictures of the teeth on the oppo- 
site side of the jaw. The first temporary molar and also the second 
temporary molar show the development of the crown and root 
plainly. Immediately above the first temporary molar in the alveolus 
can be seen the tip of the first bicuspid becoming calcified. The 
second temporary molar shows plainly the characteristic large pulp 
chamber and the delicately pencilled buccal roots. In the light 
area above the second temporary molar is the crypt of the second 
bicuspid, but no signs of calcification are seen. Immediately back 
of the second temporary molar is the first permanent molar with 
only its crown calcified. There is no appearance of the second per- 
manent molar or of the third permanent molar. 

In the lower jaw beginning behind the crypt of the second per- 
manent molar are shown the buccal cusps completely calcified. 
Directly in front of the second permanent molar is the crypt and 
calcified crown of the first temporary molar, with its light area 
below, in which lies the formative organ (dental pulp or bud) . An- 
terior to this second temporary molar the pictures are indistinct, 
but probably represent normal temporary teeth. 

The spinal column may show an absence of one or more verte- 
brae, or an additional vertebra, or lordosis or kyphosis. The main 
object in view, however, is that having seen one or two illustrative 
cases we may thus be able to recognize other anomalous conditions 
of this nature. The condition of rhachischisis is one of the principal 
forms of congenital defects of the spine, but though a Roentgeno- 
graph of this condition might be interesting from an embryologic 



DISEASES OF THE NEW-BORN. 73 

point of view, the malformation is so evident at birth that the 
Roentgen ray for diagnosis would be unnecessary. It is a disease 
of pathologic rather than of clinical interest, for not only is there 
a deficiency of the vertebral arches, but the cord itself is rudimentary. 
Comparatively few anomalies of the vertebrae have been seen which 
can be classed under diseases of the new-born and are of interest 
from a Roentgen-ray point of view. In the study of each case the 
vertebrae should be counted, and we should note whether the inter- 
vertebral discs are distinct, or are compressed, fused, or destroyed. 
The number of vertebrae may be increased or diminished, a deficiency 
in one region usually being replaced by an additional vertebra in 
another. It is to be noted, however, that the number of bones in 
the cervical region is rarely increased or diminished. An additional 
or lessened number of vertebrae in the lumbar region is of especial 
interest in connection with the technic of lumbar puncture. 

Spina Bifida. — The most common disease of the spine which 
occurs during intra-uterine life is spina bifida. This condition is 
getting to be of additional importance, since by means of the Roent- 
gen method considerable advances have been made in the treatment 
of these cases through the more precise diagnosis which can be at- 
tained by detecting the exact type, locality, and extent of the lesion 
before operation. Spina bifida is a condition in which there is a fail- 
ure of closure of the laminae of the vertebrae. At certain intra-uterine 
periods this anatomic condition is normal, but when it is found at 
full term it becomes abnormal from a developmental point of view 
and represents a distinct malformation. The laminae close normally 
at the beginning of the fourth month of fetal life, and fusion takes 
place at the base of the spinous processes from above downward. 
As the lumbar vertebrae are the last to unite, spina bifida is most 
common in the lumbar region. A true spina bifida commonly 
appears as a tumor in the lower part of the spine or in the sacrum, 



74 THE ROENTGEN RAY IN PEDIATRICS. 

and is covered with either healthy or diseased tissue, which is usually 
very thin and transparent. At times the tumor is solid, containing 
only fibrous and fatty tissue, with no connection with the spinal 
cord or canal other than a dense fibrous pedicle with no nerve tissue 
or filaments included. At other times it may be represented simply 
by a defect in the skin covered usually by a tuft of coarse hair; in 
this latter case it is called spina bifida occulta. The condition of 
pylo-nido-sinus must of course be thought of differentially, but 
would usually be readily distinguished from spina bifida. 

Plate 42 represents the photograph of a case of spina bifida 
occulta occurring in a girl three and a half years old. The muscles 
of the right thigh were atrophied. 

Plate 43 shows a Roentgenograph of the same case. The ver- 
tebrae above the sacral region do not show any numerical varia- 
tions, and not being well developed are not easily distinguishable. 
There is a definite change not only in structure but in size of the 
third lumbar vertebra. The third intervertebral disc is narrowed. 
The fourth and fifth lumbar vertebrae are larger and narrower from 
side to side with very small and irregularly shaped spinous processes. 
There is a partial sacralization of the transverse processes of the fifth 
lumbar vertebra. The sacrum presents a cleft to the left of the 
median line. A dislocation of the right femur is shown to be present, 
and is probably congenital in origin. A rudimentary acetabulum 
and a delayed development of the right upper femoral epiphysis are 
shown. 

Plate 44 represents the lumbar vertebrae, pelvis, and thighs of 
the same case. The spinous processes of the third and fourth lumbar 
vertebrae are bifid. The child was operated on, and the plate shows 
the abnormal conditions five months later, and represents an appar- 
ently satisfactory reduction of the femur. The dislocation of the 
femur was not recognized clinically. 



DISEASES OF THE NEW-BORN. 75 

RIBS 

A precise knowledge of an anomalous condition of the ribs, 
such as fusion of the ribs, an extra rib, or any malformation of the 
ribs, is often of great value when the physician wishes to determine 
the best point of entrance when performing thoracentesis. 

Plate 45 illustrates this fact. It is that of a child who showed 
a congenital fusion of the sixth, seventh, and eighth ribs on the left 
side. Especially evident are the greatly deformed fourth, fifth, 
sixth, and seventh dorsal vertebrae, and a decided scoliosis to the 
right. To be noted also in the lower lumbar region was a marked 
spina bifida (not shown in the plate). If in a case of this kind there 
happened to be a pleuritic or pericardial effusion the information 
gained from the Roentgenograph would be of infinite aid and almost 
absolutely necessary in determining the position of the heart and 
at what point the needle should be introduced. 

In cases of torticollis it is often very difficult to determine the 
cause of the condition without having recourse to the Roentgen 
method of examination. This is especially evident where the clinical 
symptoms arise from a malformation of the vertebrae or ribs. Plate 
46 explains the cause of the condition where the clinical picture 
was that of torticollis to the right in a child six years old in whom 
the Roentgenograph showed that there was a congenital cervical 
rib attached to the seventh cervical vertebra on the left side, while 
on the right side of the same vertebra there was none. On the side 
of the malformation the child will be seen to have thirteen ribs, 
instead of the twelve which normally appear on the right side. 

In connection with the ribs and spine a malformation of the 
scapula is found at times. Although this condition can usually be 
detected by the usual external physical examination, yet it is far 
more satisfactorily explained by means of the Roentgen method. 

Plate 47 shows the photograph of a boy six years old with an 



76 THE ROENTGEN RAY IN PEDIATRICS. 

elevation of the scapula on the left side. He also shows a marked 
scoliosis to the left. 

Plate 48 shows a Roentgenograph of the same deformity. In 
this picture is shown the scapula in the region of the muscles of the 
neck on the right side, while the clavicle on the opposite side is in 
its normal position. The remainder of the picture is normal. 

Plate 49 shows the same condition in an infant six months 
old. In this case the elevation of the scapula reached high up into 
the neck. There is also a left dorsal curve of the spinal column. 
The first dorsal vertebra also shows some deformity. Otherwise 
the picture is normal for the age. 

INTRATHORACIC AND INTRA-ABDOMINAL ANOMALIES 

Although the detection of the various transpositions of organs, 
as the heart in the thorax and the liver in the abdomen, is compara- 
tively simple, yet there are cases in which it is almost impossible to 
determine whether the transposition of a heart is due to a congenital 
deformity or to adhesions holding it out of position. In such cases 
as these we have to depend upon the transposition of other organs, 
such as the liver or spleen or stomach, as shown by the ray. Plate 
110, Division VI, is an illustration of this difficulty. 

ANOMALIES OF THE EXTREMITIES 

In connection with the study of the bones, especially of the 
extremities, it is well to understand that all congenital deformities 
in connection with the bones show their changes in the epiphyses. 
Among the anomalies of the new-born the malformations of the 
hands and feet appear to be the most common, but no part of the 
osseous system is exempt. Until the Roentgen ray came into general 
use these conditions could only be studied by what could be seen 
externally or at the post-mortem, although an actual and precise 
knowledge of the relation of the bones to each other was very neces- 



DISEASES OF THE NEW-BORN. 77 

sary in order to obtain the best results from operative treatment. 
Club-hand and club-foot are congenital malformations which may be 
due to an undeveloped condition of either the bones, the ligaments, 
or the muscles, and the Roentgenograph is therefore of the greatest 
importance in determining which condition is present in the especial 
individual. In the more simple forms the extremity is pulled into 
position by the action of contracted muscles or tendons. In the 
more severe forms the bones may be so misshapen that the separate 
segments are almost unrecognizable, and therefore a picture of these 
segments is required for intelligent operative interference. For 
practical use surgically we may divide the malformations of the 
hands and feet into three types : 

An extra fully developed separate digit. 

A fully developed hand or foot with one or more digits webbed, 

or with a single or multiple anomalous condition of any of 

the carpal or tarsal bones or the phalanges, metacarpal, or 

metatarsal bones. 
A hand or foot with a less number of fingers or toes than normal 

and with an imperfect development of one or more bones. 

Upper Extremities. — As illustrations of the various types of 
deformities just spoken of are the following: 

Plate 50 (Fig. 1), the hand of a child two months old, shows 
a webbed condition of the second and third phalanges. A number 
of deficiencies are also present which may be seen in the illustration. 
It is to be especially noted in this plate that none of the epiphyses 
of even the metacarpal bones are present. Otherwise the bony 
structure is fairly normal. 

Fig. 2 shows the left hand of a child one and a half years old. 
The Roentgenograph shows an extra digit, and also the fusion of 
the fifth and extra metacarpal bones. The Roentgenograph in 



78 THE ROENTGEN RAY IN PEDIATRICS. 

this case was of course of the utmost aid in determining what the 
operative treatment should be. 

Plate 51 shows a photograph (Fig. 1) of a boy ten years old 
with double congenital club-hands. The picture also shows a defi- 
ciency in the number of the fingers, the thumb being absent and two 
of the fingers of the left hand being webbed. The Roentgenograph 
(Fig. 2) of this case shows a number of anomalous conditions which 
are described in the corresponding legend. Club-hand is often accom- 
panied by an absence of the radius, and this condition is shown in 
the Roentgenograph. It is to be noted that the bones in this case 
are smaller than normal and show a deficiency in the lime salts. 
The deformities in this case are so complex that it is evident that a 
Roentgenograph was necessary if any radical surgical operation was 
to be performed. Also to be noted in this plate is the absence of 
the epiphysis of the lower end of the humerus, the slightly developed 
epiphysis of the lower end of the ulna of the right hand, the rudi- 
mentary metacarpal bone of the left hand, and the lack of develop- 
ment of the carpal bones. 

Plate 52 shows a deformity of both ulna and radius, and a 
bowing of the ulna seemingly in order to compensate for the radius, 
which is considerably shortened. 

Plate 53 shows an anomalous condition in the arm of a boy 
ten years old. The abnormal difference in size in the bones, and 
in the outline and dislocation of the radius, and also the irregular 
deposit of bone in the ulna probably arise from some unknown con- 
genital cause. 

Lower Extremities. — Plate 54 shows the photograph of the feet, 
only two toes being present, of a boy eight years old. The Roentgeno- 
graph shows a fusion of the astragalus and the os calcis. Accord- 
ing to Dwight, this abnormal condition occurs at the posterior end 
of the sustentaculum, and may be attributed to the fusion of the 



DISEASES OF THE NEW-BORN. 79 

os sustentaculi with both bones. The bones may be firmly ossified 
or they may be united by gristle, the apposed surfaces showing the 
characteristic irregular finish. Either of these conditions is decidedly 
uncommon. A Roentgenograph was manifestly very important in 
this case. 

Plate 55 shows another somewhat similar deformity of a child's 
foot in which only one toe is present. 

A very striking instance of how important to the surgeon may 
be the anomalous conditions connected with the malformations of 
the foot is represented in Plate 56. This is the foot of a child 
three years old. It shows the absence of the tarsal bones, with the 
exception of two which are very slightly developed. The metatarsal 
bones are also absent. This case was under the care of an orthopaedic 
surgeon for some time and was considered to be connected with the 
malformation of club-foot. The Roentgen ray showed the anomalous 
condition, and the knowledge received from it, if it had been obtained 
earlier, would have saved the patient months of treatment. Of 
course to understand thoroughly such an anomalous condition as 
this it is necessary to compare this picture with that of the normal 
average development at three years. 

Plate 57 shows the delayed development of the right lower 
extremity in a child six months old. There is an entire lack of devel- 
opment of both trochanters, and the upper epiphysis of the right 
femur is markedly smaller than the left. Evidently the cartilage 
has been arrested in its change into bone at an early period, while 
on the opposite side this process has continued normally, and the 
resulting shortening of the leg is shown by the ray. Plate 58 shows 
the lower legs and feet in the same case. On comparison with the 
foot of a child of the same age it shows a lack of development of the 
deformed limb and of the tarsal bones of the foot, the undeveloped 
epiphysis of the tibia, and the general irregular distribution of the 
metatarsal bones. 



80 THE ROENTGEN RAY IN PEDIATRICS. 

ANOMALIES OF THE PELVIS 

Congenital dislocations of the hip are the most frequent of and 
play an important role in the malformations of the new-born. They 
depend upon a faulty development of the acetabulum and of the 
head of the femur. Plates 59 and 60 show instances of this nature. 
These Roentgenographs are of especial importance in that they 
make evident whether the dislocation is due to a lack of development 
of the acetabulum, to an absence of the head of the femur, or to 
some other anomalous condition which it would be impossible other- 
wise to recognize during life or without operation. With the aid 
of the Roentgenograph the operation can be determined with more 
exactness than by any other method. 

Plate 59 shows the dislocation of both femora in a child twelve 
and a half years old. 

Plate 60 shows a congenital dislocation of the left femur in a 
child ten years old. 

Plate 61 represents the legs of a child where there was a con- 
genital paralysis on both sides. The cause was not determined, but 
was supposed to be the result of some congenital lesion of the cord. 
As shown by the Roentgenograph there is an undeveloped and 
atrophic condition of the acetabulum and femur. The atrophy is 
not in quality but only in size. 

BACKWARD MENTAL DEVELOPMENT— MYXCEDEMA— CRETINISM 

Plate 62 shows the hand of a case of hydrocephalus, and 
delayed development of the carpal bones in an infant twenty- 
three months old. In addition to the delayed development of 
the bones, which represent chronologically about six months of 
age, there is to be noted an anomalous ossific centre at the proxi- 
mal end of the second metacarpal bone, which may be possibly 
the trapezoid, trapezium, or an anomalous epiphysis. 



DISEASES OF THE NEW-BORN. 81 

Plate 63 shows the hand of a boy four years and nine months 
old, who was decidedly backward in his mental development, and 
whose hand shows that the wrist is developed about as much as 
would be usually found between the second and third year. 

Plate 64 shows the hand of a girl eight years old, with myx- 
oedema. Nothing especially abnormal is noticed in the bones, ex- 
cepting that the wrist presents a development about two years 
behind what would usually be normal for eight years in a girl. 

Plate 65 shows the delayed development of the carpal bones 
in the hand of a sporadic case of cretinism in a child twenty- 
seven months old. It also shows the ill-developed bones of the 
leg, and the narrow zone of proliferation which is supposed to 
occur in cases of cretinism. Fig 3 shows this narrow zone in a 
section of the femur of a cretin. This specimen is in the Warren 
Museum of the Harvard Medical School. 

CHONDRODYSTROPHY FCETALIS (ACHONDROPLASIA) 

Although various names have been used to represent this con- 
dition, investigators at present as a rule prefer to limit the term to 
chondrodystrophia foetalis. In order to recognize the disease from 
a Roentgen-ray point of view the gross anatomy and coarse histology 
should first be carefully studied. In this way the Roentgenograph 
can differentiate this disease of the new-born from such changes in 
the bones as take place in osteogenesis imperfecta, and those nutri- 
tive conditions acquired after birth, such as rhachitis and osteoma- 
lacia. The word achondroplasia was first used to represent this 
condition by Parrot in 1878; but Kaufmann, in 1892, in describing 
the pathology of the disease, spoke of it as a disturbance of the 
endochondral ossification, while the ossification on the side of the 
periosteum was perfectly normal. Later investigators have usually 
followed Kaufmann in using the name chondrodystrophia foetalis. 



82 THE ROENTGEN RAY IN PEDIATRICS. 

It is a disease of the osseous system beginning in intra-uterine life 
between the third and sixth months and usually ending at birth. 
Its effects, however, persist through life. Owing to similar macro- 
scopic appearances it is often erroneously classified as fetal rhachitis, 
but microscopically it presents marked differences. The cause is 
not known. It is usually accompanied by general malnutrition, 
and the majority of the cases die soon after birth, but the less severe 
cases are compatible with life. The characteristic changes in the 
bone result in shortened and deformed extremities, and a large square 
head and flattened nose, but the trunk usually remains normal. 
These abnormalities are brought about by a disturbance in the 
normal process of ossification of the primary cartilages. The flatten- 
ing of the bridge of the nose is due either to primary tribasilar synos- 
tosis or a failure of development which causes the base of the skull 
to be shortened. In the long bones a cartilaginous ossification of the 
epiphyses results in an arrest of development and a corresponding 
shortening. The shafts consist chiefly of periosteal bone, while the 
medullary canal is sometimes replaced by hard bone. The ends 
of the bones may be so affected by the overgrowth of periosteum 
as to produce deformities which closely resemble those of rhachitis. 
Similarly there may be at the junction of the ribs and cartilage a 
flattening of the sides of the chest, and there may be also a flatten- 
ing of the pelvis. 

Kaufmann has divided chondrodystrophia foetalis into three 
types: (1) chondrodystrophia hypoplastica, in which there is a 
failure of the development of the cartilage; (2) chondrodystrophia 
malacica, in which there is an abnormal softening of the cartilage ; 
(3) chondrodystrophia hyperplastica, in which there is excessive 
development of the cartilage in all directions. Osteoporosis and 
osteosclerosis may occur as complications. A tendency to deformity 
in these cases may be increased by fractures. Instead of the enlarge- 



DISEASES OF THE NEW-BORN. 83 

ment of the ends of the long bones due to excessive enlargement of 
the epiphyseal cartilage, as is seen in rhachitis, chondrodystrophia 
shows an overgrowth of the periosteum. The zone of proliferation 
while it is widened in rhachitis is narrowed in chondrodystrophia, 
and the vascularization in the latter disease is marked. There is 
probably no direct relation between chondrodystrophia and cretinism. 
The differential diagnosis between chondrodystrophia, rhachitis, 
osteomalacia, and other diseases by means of the Roentgen ray is 
given on page 107. Since the introduction of the Roentgen method 
of examination, a diagnosis on the living subject of the various 
intra-uterine conditions connected with the bones and with their 
epiphyses has rapidly advanced in precision. While in the past 
there has been almost inextricable confusion in the differentiation 
of these diseases, we can now make a diagnosis with a fair chance 
of its being correct. Especially to be noted is the recognition as 
distinct diseases of the conditions of chondrodystrophia foetalis, 
osteogenesis imperfecta, cretinism, and possibly fetal rhachitis. 
Up to the present time, however, no case of intra-uterine rhachitis 
which has been studied by modern methods of examination has been 
published. 

Plate 66 shows two cases of chondrodystrophia foetalis. Fig. 1 
is the picture of a girl five and a half years old, showing the flattened 
nose, comparatively short arms, and especially short legs of a case of 
chondrodystrophia foetalis. For the description of this case, see 
"Pediatrics," page 333, fifth edition. 

Fig. 2 is the picture of a boy thirteen years old, showing the 
flattened nose, the short legs, and the noticeably short arms. 

Plate 67 shows the Roentgenograph of the hand of the same 
case, Fig. 2, in comparison with the normal hand (Plate 20) of a boy 
nine years old. A number of changes besides the broad thickened 
bones will be noticed. 



84 THE ROENTGEN RAY IN PEDIATRICS. 

Durante, in 1902, stated that " the cartilage shows more vascu- 
larization than normal. It is separated from the border zone by a 
vascular fibrous band. This band diminishes in breadth inward 
and towards the centre of the epiphysis and is often represented 
only by an interstitial sclerosis of the layer of the cartilage cells, 
which are disposed parallel to the line of ossification. Below this 
the proliferation and arrangement of the cartilage cells is very 
defective. The cells, well separated in the midst of an interstitial 
substance suggesting fibrous tissue, are, as a rule, not disposed 
in columns even partially. There often is no trace of cartilage 
columns, and the cells lie isolated and scattered without order, 
even up to the edge of the line of ossification. From this there 
results the formation of bony lamellae, small, thin, and essentially 
irregular, or rather a series of points of calcified nodules irregularly 
disseminated in the marrow of the bone. A certain number of pro- 
jections of marrow occupy the line of ossification and extend toward 
this fibrous band. Below the line of ossification the medulla is rep- 
resented by a very close dense areolar connective tissue with fibres 
decidedly coarser than normal. In short, there exists an intense 
sclerosis with disappearance, or at least absence, of normal medullary 
cells." 

While the cartilaginous ossification is insufficient and defective, 
the periosteal ossification appears active, though equally pathologic 
under certain aspects. On a transverse section of the diaphysis of 
the femur, we perceive the eccentric position of the medullary canal, 
which is diminished in size. We nowhere find compact bone. These 
bony partitions may run parallel to the surface of the bone, or may 
be perpendicular to it, and at their peripheral ends may become 
lost in the internal fibre-bundles (faisceaux) of the periosteum. 
Where the periosteal layer begins to bend inwards and to calcify, 
there is a transformation of the periosteum into fibrocartilage and 
then into ossification. 



DISEASES OF THE NEW-BORN. 85 

Resume: There is present a sclerosis of the epiphyseal cartilage 
while in preparation for multiplication. A lack of serial arrangement 
of the cartilage, and a deficiency in cartilaginous ossification succes- 
sively occurs, while processes from the marrow cross the line of ossifi- 
cation. Abundant periosteal ossification is produced as well by 
means of osteoblasts as by direct calcification of the fibrous lamellae, 
but only eventuating in the formation of a spongy bone with thick 
resistant lamellse. There is sclerosis of the bone-marrow. This 
condition is entirely distinct from that known as osteogenesis imper- 
fecta, in which the periosteal ossification is especially defective. 
Mullen's case of osteogenesis imperfecta (reported in 1897) showed 
that the endochondral ossification was wholly normal. In this case 
no real periosteal bone formation was anywhere established. 

The shafts of the bones often show great thickening and short- 
ening of the cortical substance, and overgrowth of the bony 
epiphysis is so marked that it often appears to overlap that of the 
epiphyseal line. 

In examining the living conditions in these cases, first the peri- 
osteum shows great thickening; second, the cortical substance is 
broader and thickened; and third, the medullary canal is narrowed, 
sometimes showing its cavity to be replaced by hard cortical tissue. 
It is seen that the arrest of development and consequent shortening 
of the long bones is due to the cartilaginous ossification of the epiphy- 
ses, and it is very evident that these abnormalities are brought 
about by the disturbance in the normal process of ossification in 
the primary cartilage. Although many of these cases are born in 
such a condition that they do not live, yet the milder cases recover, 
and it is important to differentiate by means of the Roentgen ray 
this class of cases from osteogenesis imperfecta, rhachitis, and various 
anomalies such as the shortening shown in Plate 57. 

The examination by the Roentgen method of cases of chondro- 



86 THE ROENTGEN RAY IN PEDIATRICS. 

dystrophia gives results as characteristic as the clinical examination, 
though varying in certain details of the bony change which takes 
place. A description of the Roentgen pictures of these cases is not 
definite unless we divide them into two groups and consider the age 
of the individual. 

1. The cases which are seen up to pubescence. 

2. The cases of pre-pubescence with marked deformities of the 
limbs, and in which a secondary lesion of the joint is found. 

In the first group of cases the typical Roentgen picture of a 
given bone, for instance the tibia, will show a bone that is shorter 
and wider than the bone of a normal child, but which has a well- 
developed ossific centre for the given age under examination. The 
picture produced by the bone generally compares well with that of 
a normal child. Deformities of the shaft, with the exception of 
bowing, are rare in this group. The cortex is thicker, particularly 
in the middle of the shaft, showing considerable deposit of bone, 
but thinning out towards the diaphysis. The medulla, though small 
at the middle of the shaft, is increased proportionately with the 
thinning of the cortex. The bone structure is in some cases prac- 
tically normal as compared with a normal child, but in the majority 
of cases is coarser and sometimes a more irregular deposit is appar- 
ent, particularly in the diaphyses. The most characteristic appear- 
ance of the long bones is that near the epiphyseal ends the diaphyses 
are spread like a cup (Plate 67). This produces a T-shaped outline 
without any disturbance of the epiphyseal line or zone of prolif- 
eration, though it may be uneven and show more or less fantastic 
shapes as compared with a normal individual. They are, however, 
not so uneven as is seen in diseases of nutrition, such as rhachitis 
(see Plate 88, Division IV), where there is a definite disturbance 
of the zone of proliferation, but where the ossific centres have been 
well formed and the epiphyses are apparently fitted into the cup- 



DISEASES OF THE NEW-BORN. 87 

like diaphyseal ends. In this first group of cases there is nothing 
seen in the Roentgen plates which could be confused with rhachitis. 

The second group of cases is characterized by extremities extra- 
ordinarily shortened in comparison to the body. The upper arms 
and thighs are shortened in comparison to the forearms and legs, 
but are distinguished from the first group in that the osseous system 
shows more definite pathologic changes in the joints, such as scoliosis, 
kyphosis, lordosis, coxa vara, genu valgum or varum, with ankylosis, 
partial or complete, of one or more joints, either owing to a mechani- 
cal distribution or to a pathologic change. In the Roentgen exami- 
nation of these cases, although the underlying appearance of the 
bone is that of the first group, we have added a more definite change 
of the articular surfaces of the joints and of the epiphyses in general. 

In chondrodystrophia there is a rather narrow but fairly regular 

zone of proliferation, the shafts are short, not bent, and usually 

thick. 

OSTEOGENESIS IMPERFECTA 

SYNONYMS: FRAGILITAS OSSIUM, IDIOPATHIC OSTEOPSATHYROSIS 

This disease is characterized by brittleness of the bones and 
multiple fractures. It has been shown to have a definite pathology 
of its own. As at birth the clinical diagnosis is often obscure and 
unsatisfactory, the Roentgenograph becomes of importance in differ- 
entiating between this condition and chondrodystrophia foetalis, 
or possibly a rare case of infantile osteomalacia. In considering 
this class of congenital diseases we must remember that the skeleton 
at birth is still in its formative stage, and it is therefore difficult to 
distinguish between the effects of disease and those of malformation. 
The diagnosis of fetal diseases of the bone has been greatly confused, 
since the same name has been given to different pathologic and 
clinical conditions, and different names to the same disease. As is 
shown by Nichols, however, osteogenesis imperfecta has a distinct 



88 THE ROENTGEN RAY IN PEDIATRICS. 

pathology of its own and should be entered under its own heading. 
It differs from osteomalacia, chondrodystrophia, and rhachitis. 
I have been unable to find any reliable modern report of a histo- 
logic examination made of a case of osteomalacia occurring at 
birth, although of course it is possible that it may occur. Osteo- 
genesis imperfecta may be said to be an abnormal intra-uterine 
condition resulting in multiple fractures during intra-uterine life 
or infancy. Clinically in this disease the infants are smaller than 
normal and their extremities are short and usually curved. The 
skin is thick and cedematous, and their skulls are probably imper- 
fectly ossified. A case of osteogenesis imperfecta was referred to 
me by Dr. R. W. Lovett, and I had the infant under my care until 
its death at the age of ten months. The case was minutely examined 
and studied post mortem by Dr. A. G. Nichols. According to his 
examination the following pathologic conditions were found : 

"The new trabecule are formed by direct metaplasia of persist- 
ing cartilage cells into bone, whereas the normal development of the 
trabecule of bone is formed by apposition of bone, by osteoblasts 
upon a persisting cartilaginous matrix. In this condition the bone 
cells are large, oval, not stellate, and show no tendency to form con- 
necting canaliculse. The bones in this condition are very imperfectly 
formed, and would suggest a general diseased condition, the character 
of which is not perfectly clear. The fibrous matrix is not calcified 
as in normal bone, and the capsules of the cartilage cells do not 
rupture. The periosteum does not form normal bone, is much thicker 
than normal, and is incomplete. The Haversian canals are supple- 
mented by large marrow spaces and the trabecule in the marrow 
canal are fewer. Near the epiphyseal lines and in the marrow spaces 
of the cortex the marrow consists of an oedematous, myxomatous 
connective tissue. The whole process of the development of the 
bone is checked and is of an abnormal kind. Metaplasia of cartilage 



DISEASES OF THE NEW-BORN. 89 

is very much greater in this condition than normal, while apposition 
of bone is much less. The bones show lessened density and appear 
thin and atrophied. The medullary cavity seems to be increased at 
the expense of the cartilage. 

"The. epiphyseal lines are sharp, but perhaps less regularly so 
than normal. Fractures are numerous and appear clearly in the 
Roentgenograph. The bones show increased radiability. 

" It is improbable that this process is identical with the process 
which occurs in acquired fragility of the bones. " (For a more com- 
plete histologic report of this condition, see British Medical Journal, 
October 4, 1906.) 

Plate 68 shows the forearm of a girl two years old. Clini- 
cally there were no deformities, except a tendency to valgus of 
the left foot. The shafts of the long bones, especially of the radius, 
were thickened and heavy. Numerous irregularities simulating 
a callus were detected, and were especially well marked on the 
left humerus. The Roentgen examination showed that the pha- 
langes of the fingers were regular in shape, excepting that the 
proximal portions were toothed and cup-shaped. There was very 
little cortical bone present, and the bony structure was coarse with 
very little evidence of the bone. The carpal bones were delayed in 
development. The radius showed evidence of at least two fractures, 
and the ulna of one or more. 

The lateral view of the leg, Plate 69, of this same subject, 
shows a fracture of the femur without any evidence of cell formation. 
The outline of the bone was regular, excepting for the fracture. 
There was very little cortex. The medulla was increased propor- 
tionately and showed marked increase of radiability. There were 
coarse trabecule in the structure of the bone. The epiphyses were 
poorly defined and there was a marked increase in the zone of pro- 
liferation of all the bones. A fracture was also apparent in the 
fibula. 



90 THE ROENTGEN RAY IN PEDIATRICS. 

Plate 70 shows the leg of a girl twenty-five months old. There 
was no history of previous multiple fractures in the family. The 
legs and arms of the child seemed very weak at birth and they 
seemed to be very sensitive to touch. The right arm just below the 
elbow showed on palpation displacement, but the motion of the 
elbow was not impaired. Nothing abnormal was discovered about 
the joints. The Roentgenograph showed an unreduced fracture of 
the lower end of the humerus, and three fractures of the left arm, 
also a fracture of both femurs. The lateral view of the leg showed 
a marked overgrowth of periosteum, with evidence of fracture in 
the middle of the shaft. No formation of callus was present. The 
cortex was ill defined and in places absent. The epiphyses were 
fairly regular, but there was considerable disturbance of the diaphy- 
seal portion of the bones which were toothed and cup-shaped. A 
fracture of the tibia and of the fibula was seen to be present. 

FETAL RHACHITIS 

Although it is possible that rhachitis may be of fetal origin, 
I have been unable to find satisfactory proof of this in any reported 
case where modern methods of examination have been employed, 
so that the existence of intra-uterine rhachitis is still sub judice. 

OBSTETRICAL PARALYSIS 

The most common form of paralysis of the arm occurring at 
birth is that of the upper arm, although that of the lower arm type 
occurs at times, and both the upper and lower arm type may be 
present together. A knowledge of the anatomical conditions, especi- 
ally of the upper arm type, which represents these forms of paralysis, 
is important in connection with the differential diagnosis from 
various other forms of paralysis or pseudoparalysis, especially 
poliomyelitis anterior. This is especially true in cases of obstetrical 
paralysis where this condition first comes under the physician's 



DISEASES OF THE NEW-BORN. 91 

observation in older children, especially where the whole arm is 
involved. There is no need of entering into the question of etiol- 
ogy, as this question has been fully discussed by a number of 
writers, as by Thomas on the lower arm type, Boston Medical and 
Surgical Journal, October 19, 1905, by Stransky, Centralblatt s. d. 
Grenzgeberte d. Med. u. Chi., 1902, and by Bullard, Amer. Journal 
Medical Sciences, July, 1907, the latter paying especial attention to 
the upper arm type. It is now conceded pretty well that the upper 
arm type at least is produced by injury due to stretching of the 
fifth and sixth cervical nerves in the neck, which may be more or 
less ravelled out or torn asunder. The external points for diagnosis, 
both by manual examination and electrical reaction, hold their 
own place in importance. In some cases when the recognition of 
the condition is uncertain, the Roentgen method is especially useful 
for completing the examination and determining the lesions which 
are characteristic of obstetrical paralysis pure and simple without 
other injuries. There may, however, be a number of other anatomic 
conditions, resulting from fractures of the clavicle and arm and dis- 
location of the shoulders, which may so complicate and obscure the 
original injury of the cervical nerves that a precise and definite 
diagnosis cannot be made without the aid of the Roentgen method. 
It is therefore necessary that we should be familiar not only with 
the normal anatomic development of the shoulder, elbow, and wrist 
at different stages of growth, but also should recognize the deformi- 
ties of these parts which are dependent on the obstetrical paralysis 
itself. 

The following Roentgenographic plates illustrate cases of 
obstetrical paralysis of the upper arm type. If the injury has existed 
for some time after birth we find in these cases evidence of atrophy 
or non-development of the bones, in addition to the muscular atrophy. 

Plate 71 shows a case of obstetrical paralysis in a boy eight 



92 THE ROENTGEN RAY IN PEDIATRICS. 

years old. Within twenty-four hours after birth, paralysis of the 
left upper arm was noticed. When the child was three years old 
the paralysis of the deltoid was still marked and some atrophy 
of the left shoulder. At present he can elevate his arm only to the 
level of the shoulder and cannot supernate the upper arm beyond 
the median line. External rotation was also found to be impaired. 
There was also marked shortening of the left arm, with atrophy of 
both the upper and lower arm and of the scapula. A Roentgeno- 
graph of this case showed a rudimentary development of the glenoid 
cavity and of the head of the humerus. Ossification of the upper 
epiphysis of the humerus and of the epiphysis for its greater tuber- 
osity was found to be delayed. The scapula was smaller than on 
the other side. The superior angle of the scapula was elevated. 
The acromial process was shorter and narrower than that on the 
opposite side and was delayed in its development. There was no 
apparent atrophy of the shaft of the humerus. 

Plate 72 shows a boy six years old. An hour after birth it 
was noticed that neither of the arms could be moved. When he was 
three years old he could use the left upper extremity from the shoul- 
der. He could flex his forearm, but could not completely extend it. 
He could not pronate or supernate, and could raise his arms only 
about the level of the mammae. Seven months later the left shoul- 
der was found to be higher than the right, the head of the humerus 
being pushed forward to the left. The scapulae were of equal size, 
measuring 9 cm. in length. The atrophy of the arm and forearm 
was noticeable. There was a primary rotation of the arm at the 
shoulder, and the shoulder was elevated. The movements were 
for the most part free, although there were adhesions between the 
shoulder and the scapula. The Roentgenograph shows the left 
shoulder to be lower than the right, and there is considerable atrophy 
in size of the shaft of the humerus. The scapula was a little smaller 



DISEASES OF THE NEW-BORN. 93 

on one side than on the other, but otherwise seemed to be normal. 
There was some delayed development of the epiphysis of the 
humerus. 

Plate 73 shows the condition of obstetrical paralysis in a girl 
who on the third or fourth day after birth was noticed to be unable 
to move her right arm. She could move her fingers. The arm 
could not be moved at all, and practically there was no voluntary 
movement of the entire arm except in the fingers. Posterior motion 
of the shoulder was painful and there was a distinct click of the 
clavicular humeral joint, but no definite crepitus. A Roentgeno- 
graph taken four months later showed a rudimentary development 
of the glenoid cavity, delayed development of the epiphyses, and 
the scapula to be very much smaller than normal, with a prominent 
superior angle and a rather large acromial process. 



PLATE 41. 

HEAD AND NECK. 

Boy, age 6 years. (Life size.) 

A. Orbit. 

B. Sphenoidal sinus. 

C. Artifact. 

D. Antrum. 

E. First temporary molar. 

F. Second temporary molar. 

G. First bicuspid. 

H. First upper permanent molar. 
I. Second lower permanent molar. 
/. First lower permanent molar. 

R. Points to an anomalous condition of the upper cervical 
vertebrae. 



Plate 41 






PLATE 42. 
SPINA BIFIDA OCCULTA. 

Girl, age 3£ years. (Same subject as Plates 43 and 44.) 

The arrow points to hair and skin which cover the defect in 
the vertebrae. 

Congenital dislocation of right hip. 



Platje 42 




PLATE 43. 
SPINA BIFIDA OCCULTA. 

Girl, age 3J years. (Same subject as Plates 42 and 44.) 

A. The narrowed third lumbar vertebra. 

B. The narrowed third intervertebral disk. 

C. Sacralization of the left fifth lumbar vertebra. 

D. Just to the right and below the point of the arrow is 

fissure of the first body of the sacrum. 



Plat*] 43 




"<$?'' 



■fM 











PLATE 44. 
SPINA BIFIDA OCCULTA. 

Girl, age 3^ years. (Same subject as Plates 42 and 43.) 

The arrow points to the right hip after reduction. 

The deformities of the vertebrae and sacrum are the same 
as in Plate 42. 

Note the retarded development of the upper epiphysis of 
the right femur in comparison with that of the left. 



Plate 44 











/ 



* 



PLATE 45. 
FUSION OF RIBS. MARKED SCOLIOSIS OF CONGENITAL ORIGIN. 

Child, age about 4 years. (Reduced 27%.) 

A. Hyoid bone. 

B. Wedged dorsal vertebrae. 

C. Fusion of ribs. 



Plat*: 45 




PLATE 46. 
CONGENITAL TORTICOLLIS, 

Boy, age 6 years. (Reduced 38?% ) 

A. Extra rib. 

B. First rib. 



Plate 46 




PLATE 47. 
CONGENITAL ELEVATION OF SCAPULA ON LEFT SIDE. 

Boy, age 6 years. 

A. Elevated scapula. 

B. Scoliosis. 



Plate 47 




PLATE 48. 
CONGENITAL ELEVATION OF RIGHT SCAPULA. 

Boy, age 6 years. (Reduced 39%.) 

The arrow points towards the superior angle of the scapula. 



Plate 48 





/ 






PLATE 49. 
CONGENITAL ELEVATION OF THE RIGHT SCAPULA. 

Infant, age 6 months. (Reduced 16%.) 

A. Scapula. 



Plate 49 




* 



\ 



w** 



PLATE 50. 

(Life size.) 

Fig. 1. Infant, Age 2 Months. The Arrow Points to the 
Webbed Fingers. 

Fig. 2. Infant, Age 1J Years. Extra Digit. 

A. Extra digit. 

B. Extra metacarpal bone; fusion with the fifth meta- 

carpal bone. 



FIG. 1 



Plate 50 










■ 



FIG. 2. 




^B 






v/*' 



■ 




PLATE 51. 
CONGENITAL DEFORMITY OF HANDS AND ARMS. 

Boy, age 10 years. 

Fig. 1. Photograph of the Arms of a Boy 10 Years Old. 

Fig. 2. Shows the Absence of the Radius on the Right 
Side, and the Irregular Development of the 
Lower End of the Right Humerus. 

Normal development of the upper end of the right ulna. 

Two small ill-developed carpal bones are seen and a very 
slightly developed epiphysis of the ulna. 

The left arm shows an ill-developed lower end of the humerus 
with an irregular and abnormal lower epiphysis. Neither radius 
nor ulna is seen in this arm. The carpal bones are considerably 
more developed than in the right wrist; there is an extremely 
irregular development of the first finger. The thumb is absent. 



fig. 1. Plate 51 





FIG. 2. 




PLATE 52. 
MALFORMATION OF THE RADIUS AND ULNA. 

Infant, age 8 months. 

A. Marks the fusion of the head of the radius with the upper 

end of the ulna. 

B. Capitellum. 



Plate 52 




PLATE 53. 
CONGENITAL DISLOCATION OF THE RADIUS AND ULNA. 

Boy, age 10 years. (Reduced 25%.) 

A. Marks a bone cyst at the lower end of the ulna. 

B. Marks the dislocation of the upper end of the radius. 

C. Capitellum. 

D. Upper epiphysis of the radius. 

E. External condyle of the lower end of the humerus. 



Plate 53 




PLATE 54. 
CONGENITAL DEFORMITY OF FOOT. 

Boy, age 8 years. 

Fig. 1. Photograph Showing only Two Toes. 
Fig. 2. Roentgenograph of the Same Foot. 

A. Marks the fusion of the os calcis with what was 

probably the astragalus. 

B. Points to the first metatarsal bone. 

C. Points to the second metatarsal bone, 

D. Points to outline of the tissues of the heel. 

E. Points to the tendo Achillis. 



FIG. 1. 



PIRATE 54 




FIG. 2. 





PLATE 55. 

ROENTGENOGRAPH OF A CONGENITAL DEFORMITY 
OF THE FOOT. 

(Life size.) 

Shows one toe and a rudimentary second toe. 



Plate So 




\ 



PLATE 56. 
UNDEVELOPED FOOT. 

Child, age 3 years. (Life size.) 

Congenital absence of the tarsal bones, only two small 
ossific centres appearing, probably the os calcis and the astrag- 
alus. 

The lower epiphyses of the tibia and fibula are present. 

Note the meshes in the fat tissue of the heel in contrast 
with the cartilage in the tarsal region, the muscles and the 
tendo Achillis. 



Plate 56 




: 




PLATE 57. 
CONGENITAL DELAYED DEVELOPMENT OF THE RIGHT LEG. 

Infant, a<ie 6 months. (Patient of Di. John Lovett Morse.) (Same subject as Plate 58) 

(Reduced 17%.) 

The arrow points towards the small, ill-developed upper 
epiphysis of the right femur. 

Note the shortened femur and the small size of the femur, 
tibia, and fibula in comparison with the left leg. 



Peate 57 




PLATE 58. 

Same subject as Plate 57. (Reduced 29%) 



Shows the lower part of the tibia and fibula and the foot. 
The arrow points towards the very small and poorly devel- 
oped ossific centre of the lower epiphysis of the tibia. 



PT.ATE 58 




PLATE 59. 
DOUBLE CONGENITAL DISLOCATION OF THE HIP. 

Girl, age 12^ years. (Reduced 52%.) 

A. Marks the wandering acetabulum on the left side. 

Jj. Marks the upper epiphysis of the left femur. 

C. Marks the true or normal position of the acetabulum. 



The same deformity of the acetabulum is seen on the right 



side. 



Plate 59 




PLATE 60. 
CONGENITAL DISLOCATION OF THE LEFT FEMUR. 

Boy, age 10 years. (Reduced 37%.) 

A. Shows the rudimentary ischiatic portion of the acetabulum. 

B. Marks the iliac portion of the acetabulum. 

Note the rudimentary condition of the epiphysis , and of 
the neck and shaft of the left femur. 

Note also the atrophy of size of the left femur in comparison 
with the right femur. 



Plate 60 




PLATE 61. 

ATROPHY IN SIZE OF BOTH FEMORA DUE TO PARALYSIS 
OF THE LEGS. 

Infant, age about 2 years. (Reduced 31%.) 

A. Marks the ill-defined acetabulum. 

The cause of this condition was unknown. 



Plate 61 



PLATE 62. 

AN ANOMALOUS EPIPHYSIS OF THE SECOND METACARPAL BONE 
AT ITS PROXIMAL EXTREMITY, OR IT MAY BE THE 
TRAPEZOID OR TRAPEZIUM. 

(Life size.) 



^ 



Pi, ate 62 



4 








i 



PLATE 63. 
RETARDED DEVELOPMENT OF THE BRAIN AND HAND. 

Boy, age 4 years and 9 months. (Life size.) 

The hand shows a development of between two and three 



years. 



Plate 63 




v 








m 




PLATE 64. 
MYXCEDEMA— RETARDED DEVELOPMENT. 

Girl, age 8 years. (Life size.) 

The carpal bones show a development of six years. Other- 
wise normal. 



Plate 64 




PLATE 65. 
IRREGULAR DEVELOPMENT. 

Girl, age 27 months. (Same subject as Plates 115, 116, and 117.) 

Fig. 1. The Development Compares to that of the Latter 
Part of the First Year. 

Fig. 2. Shows Small Bones in Comparison with what their 
Development should be at 27 Months. 

The arrow points to the narrow zone of proliferation. 

Fig. 3. Section of Cretin Bone. 

The cut shows a section from the bone of a cretin. The 
narrow zone of proliferation exemplifies well what is said in the 
text. 



Plate 65 



FIG. 1. 




FIG. 2. 




FIG. 3. 




Z.P 




PLATE 66. 

CHONDRODYSTROPHY FGETALIS. 

Fig. 1. A Girl 5^ Years Old. 

Fig. 2. A Boy 13 Years Old. 



FIG. 1 



Plate 66 

FIG. 2. 





PLATE 67. 
RETARDED DEVELOPMENT OF THE PISIFORM BONE. 

Same subject as Plate 66, Fig. 2. (Life size.) 

Marked shortening and broadening of the metacarpal bones 
nd the phalanges. Slight irregularity of structure. 



Plate 67 




PLATE 68. 
OSTEOGENESIS IMPERFECTA. 

Girl, age 2 years. (Life size.) 

A. Fracture about the middle of the radius. 

B. F'racture of the upper third of the radius. 

C. Thickening of periosteum and old fracture about the lower 

third of the ulna. 

D. Marked fracture about the upper third of ulna. 

Xotc the slight development of the cortex and the compara- 
tive increase in the size of the medullary cavity. Also the great 
irregularity of the outlines of the bones. 



,: 




I 



Plate 68 





PLATE 69. 
OSTEOGENESIS IMPERFECTA. 

Same subject as Plate 68. (Reduced 7i%.) 

A. Marks fracture of the upper third of femur. 

B. Marks fracture of the lower third of fibula. 



Pjlate 69 




PLATE 70. 
OSTEOGENESIS IMPERFECTA. 

Girl, age 25 months. (Reduced 6%.) 

A. Marks a fracture of the upper third of the femur. 

B. Marks a fracture at about the middle of the fibula. 

Note the great irregularity of outline and the almost com- 
plete absence of the cortex of the femur, tibia, and fibula, also 
the marked proliferation of the tissues and the periosteum. 



Plate 70 





*s 




PLATE 71. 
OBSTETRICAL PARALYSIS OF THE LEFT ARM. 

(Reduced 59%.) 

The shaft of the humerus shows slight atrophy in size in 
comparison with that of the right arm. 

.4. The undeveloped glenoid cavity on the left side. 
B. The markedly elevated scapula with its irregular angle on 
the left side. 

A. The coracoid process of the scapula on the right side. 

B. The acromial process on the right side. 



Pirate 71 



j 




PLATE 72. 
OBSTETRICAL PARALYSIS OF THE LEFT ARM. 

Boy, age 6 years. (Reduced 55%.^ 

Mark the atrophy in size of the left arm and shoulder in 
comparison with that of the right. 



Plate 72 




PLATE 73. 
OBSTETRICAL PARALYSIS OF THE RIGHT SHOULDER. 

Girl, age 4 months. (Reduced 29%.) 

A. Marks the rudimentary glenoid cavity. 

B. Marks the acromial process. 



Plate 73 




m^^M 



i 






Division IV 

DISEASES OF NUTRITION 

In contradistinction from those diseases which have a distinct 
etiology and which can be classified according to their etiological 
factors, is a class in which abnormal conditions of all the tissues of 
the body arise seemingly from lack of proper hygienic surround- 
ings and from poor food. This group comprises osteomalacia, infan- 
tile atrophy, scorbutus, and rhachitis. These diseases so essentially 
belong to the early periods of life and are so obscure in their etiology, 
while presenting each in its own peculiar manifestations a clear 
picture of a vice of nutrition, that for the present we must classify 
them by themselves as diseases of nutrition. The recognition of 
the early lesions of these diseases is important, as it is in the very 
beginning that the later and more serious manifestations may be 
obviated. Although they may be amenable to treatment, yet they 
render the individual infant more vulnerable to disease as it grows 
older, and leave its susceptible tissues in such a condition that 
when it is exposed to specific infections these infections are more 
dangerous to life on account of the lessened resistance of the tissues. 
The Roentgen method of examination is especially valuable in this 
class of cases, since by it alone the earliest abnormal changes which 
correspond to the special condition can be recognized and its treat- 
ment begun before more pronounced symptoms and graver lesions 
lead us to suspect that it is present. It is in this class of diseases, 
as well as in that which is represented by such infectious processes 
of the bones as osteomyelitis and tuberculosis, that it is especially 
necessary to first carefully study the pathologic lesions as shown 
by post-mortem examinations before attempting to diagnosticate 
them by means of the Roentgen method. These examinations and 

95 



96 THE ROENTGEN RAY IN PEDIATRICS. 

studies of dead histologic conditions are often invalidated because 
the various dead lesions are terminal processes and thus do not show 
the characteristic lesions which during life represent the actual 
pathology of the especial disease. This, however, is in so many cases 
only a presumable difficulty that there is no question but that 
if we recognize this pathologic fact we can recognize sufficiently 
in the Roentgen picture the typical gross lesions which will enable 
us to diagnosticate all the diseases just mentioned during life. That 
the Roentgen method of examination can accomplish this has been 
clearly proved, so that to-day we are in a position where an early 
diagnosis is almost always possible and where appropriate treat- 
ment can be begun at once. This group of diseases is assuming a 
more and more important position among the morbid conditions 
belonging to the early years of life. It is becoming evident that 
it is more far reaching in its effects and influences to a much greater 
degree all the diseases of early life than in former years was thought 
to be possible. The prognosis in those diseases which have a defi- 
nitely determined etiology is markedly graver where such diseases 
occur in an infant who is suffering from one of the general dis- 
turbances of nutrition. In this respect especially both rhachitis 
and infantile atrophy have come to play a great and important 
role in our study of infantile diseases in general and in their thera- 
peutics. 

OSTEOMALACIA 

Osteomalacia is a disease which occasionally occurs in chil- 
dren, but not so frequently as in adults. It causes softening of 
the bone and in this respect is somewhat similar to rhachitis. 
According to Ziegler, there is an absorption of lime salts, beginning 
first at the medullary cavity and proceeding outward. The epiphyses 
arc not notably affected by the continuance of the absorptive process, 
but the cortical bone becomes spongy and decalcified, and in the 



DISEASES OF NUTRITION. 97 

severest cases there may remain little but marrow and periosteum. 
The opinion is generally held that in osteomalacia the layer of osteoid 
tissue results from decalcification, while in rhachitis a similar layer 
represents a new growth deficient in lime salts. According to Buck 
and Bryant osteomalacia pathologically consists principally in decal- 
cification of the old bone with a simultaneous formation of new 
bone, which, however, remains imperfectly calcified. The process 
of decalcification begins at the periphery of the bone trabeculse 
and gradually extends to the deeper parts. The line of demarcation 
between the normal and diseased bone is sometimes even and con- 
tinuous, but may be irregular with excavations resembling Howship's 
lacunae. There may be an intermediate zone in which the lime salts 
are not completely removed but remain in the form of a crumbling 
detritus. The periosteum is likely to be thickened and vascular 
and the medulla resembles that of infancy in its gross appearance. 
Spontaneous fractures and various distortions may occur in osteo- 
malacia and the thorax is apt to be flattened laterally. Osteo- 
malacia is recognized clinically in children as a rare condition, but 
it has not yet been proved that it may not occur as a disease of the 
new-born. No modern and exact histologic examinations, how- 
ever, have been made of infants at birth which have shown the 
pathology of the osteomalacia of post-natal cases, and it is still 
uncertain as to how early this condition may appear. It has there- 
fore been thought better to provisionally classify osteomalacia with 
diseases of nutrition, although such classification is manifestly 
empirical. Cases examined by the Roentgen method give a notice- 
able and characteristic picture. The general development of the 
skeleton is normal. The bones are generally a little longer and a 
little narrower than normal, with or without deformity or fractures. 
Usually one or more fractures of the bones, commonly the femur, 
are found, which fail to unite, and a deformity results from super- 

7 



98 THE ROENTGEN RAY IN PEDIATRICS. 

incumbent weight. At the point of fracture very little formation of 
new bone, represented by a callus, will be seen, though at certain 
portions of the bones there will be a very dense, definite cortical 
bone giving the so-called pencilled outline. Marked increased 
radiability of certain portions of the bones is seen. The irregular 
cortex, with more or less osteoid tissue, is apparent without any 
great change in the medulla or in the structure of the bone except- 
ing a lack of density. The knowledge which we have derived from 
studying the living pathologic anatomy in these cases is simply 
what we should expect from the post-mortem findings, namely, that 
it is a condition of osteoporosis, which accounts for the increased 
radiability and corresponds to the low atomic weight. According 
to Buck and Bryant the Roentgenographic pictures present: 

Cystic formation with medullary and cortical destruction. 

Acute bowing and angular bending of the bones. 

Large amount of partly calcified callus and cartilage at the 

seat of a spontaneous fracture. 
Diminution of lime salts. 

Our experience at the Children's Hospital leads us to believe 
that many of the details of the Roentgenographs of living cases of 
osteomalacia correspond to those seen in osteogenesis imperfecta, 
but the dead pathology shows the two diseases to be very different. 

Plate 74 shows the photograph of a girl seven years old with 
the general clinical signs of osteomalacia. Especially to be noted in 
Pig, 2 is the bowing of the upper part of the left femur. Ever since 
the child was able to walk there had been a tendency to bending of 
the extremities without adequate apparent trauma. Fracture or 
something closely allied to it had been suspected in the right femur, 
but nothing definite was detected until the Roentgenograph dis- 
closed the condition shown in the plate. 



DISEASES OF NUTRITION. 99 

Fig. 1 shows where a break in continuity was found in the 
upper part of the shaft of the right femur without the callus or a 
lesion which would be found in the fracture of a normal bone. In 
the same region on the left side, as is seen in the plate, there is a 
decided bending. A coarse arrangement of the structure of the 
bone, with increased absorption of lime salts, is seen in the neck of 
the left femur. 

INFANTILE ATROPHY 

A condition of the tissues called infantile atrophy, which is 
essentially one of infancy and early childhood, and most com- 
monly occurs in the first six months of life, is usually classified 
among the diseases of nutrition. No specific pathologic lesions 
have been found in these cases. They merely show extreme 
anaemia of all the soft tissues without demonstrable disease of any 
of the organs. It has been thought possible that infantile atrophy 
is merely a form of starvation. Starvation, however, even in its 
most aggravated forms, in most cases quickly responds to special 
manipulation of the food, while infantile atrophy shows such resist- 
ance to all kinds of treatment and to all manipulation of the food 
that at present, although ignorant of the cause of the disease, 
beyond its possible connection with food, I assume it as an entity. 
Roentgenographs show, so far as I have been able to determine 
by a careful study, nothing which has not already been determined 
at autopsies, that is, we are still absolutely ignorant of the etiology 
of infantile atrophy, and know nothing of its pathology beyond a 
wasting of all the tissues. 

Plate 75, Fig. 1, is the photograph of a girl about twelve months 
old. The progressive and extreme emaciation and the resistance 
to all of the most approved modern methods of feeding of this 
class of cases showed that it was not a simple case of starvation. 
(For a discussion of this condition see "Pediatrics," 5th ed., p. 341.) 



100 THE ROENTGEN RAY IN PEDIATRICS. 

Fig. 2 is the Roentgenograph of this same case. The lower 
half of the femur, the knee, and the tarsal bones are shown. To 
be noted are the clear-cut, smooth epiphyseal lines of a perfectly 
normal condition. The cortex is possibly somewhat more dense 
than normal, as shown by a certain amount of decreased radiability, 
but there is nothing sufficiently marked to allow us with the present 
knowledge which we possess of interpretation to make the diagnosis 
of infantile atrophy from the Roentgenograph, although the clinical 
aspect of the case readily makes the diagnosis. 

The differential diagnosis from general tuberculosis is at times 

exceedingly difficult, so that Roentgen evidence if present is 

extremely valuable. 

SCORBUTUS 

Scorbutus, as it manifests itself in early life, and usually in the 
first year and a half, is closely related to the scorbutus of later life. 
It is a constitutional disease closely associated with imperfect nutri- 
tion, and plays so definite a role in infancy that it is usually accepted 
as a special disease of infancy. It is characterized by anaemia 
and a tendency to hemorrhage, and in most cases is accompanied 
by a condition of the gums which is present in stomatitis ulcer- 
osa, the latter condition, however, only occurring when teeth are 
present. The tendency to hemorrhage, although it may be from 
any organ, is in most cases so common in the bones that the use of 
the Roentgen ray in determining the disease becomes invaluable. 
There may be deep hemorrhages into the muscles and occasionally 
about or into the joints, but the hemorrhage is essentially subperios- 
tal and confined chiefly to the long bones. The femora are most 
commonly affected and there is a tendency to separation of the 
epiphyses. It is the subperiosteal hemorrhage of greater or less 
extent which when recognized in the Roentgenograph aids us in 
making a differential diagnosis from other diseases, which manifest 
their primary lesions in other parts of the bones. We should notice 



DISEASES OF NUTRITION. 101 

first whether there is a greater or less area of fatty tissue, or whether 
or not there is infiltration. Second, we should examine the muscles 
as to whether they are infiltrated, atrophied, hypertrophied, or 
present a clearly defined outline. Third, we should observe whether 
the periosteum can or cannot be seen in the picture. In the latter 
case we must look further for disease by examining the cortex of the 
bone and finally its medullary cavity. If, on the contrary, the peri- 
osteum can be seen we must determine whether we are dealing with 
a thickened periosteum, or with a periosteum separated from the 
cortex. In the latter case we should decide whether regeneration of 
the periosteum and bone formation has begun (as this is the process 
by which repair takes place), or whether it is the lessened radiability 
of a fresh exudation beneath the periosteum. If we find that there 
is a decided bulging of the periosteum, and a certain amount of 
infiltration of the surrounding tissues, we are led to suspect that we 
have a subperiosteal effusion, but whether it is blood or pus the 
Roentgenograph, according to our present interpretation, does not 
tell us. The symptoms differ greatly according as an acute pain- 
ful localized condition is present, depending upon the rapid process 
which occurs in osteomyelitis, or whether the condition is the slow, 
subacute clinical sequence of an essentially chronic constitutional 
disease such as scorbutus. In the latter case acute pain is usually 
absent if the affected part is not disturbed. If the diagnosis of 
scorbutus has been made the Roentgenograph will when taken 
from time to time show whether the pathologic process is increasing 
or diminishing. It will also show the degree to which the periosteum 
has been stripped from the cortex and whether it has begun to 
invade a joint. All this knowledge acquired by the Roentgen ray 
is of the greatest importance in the treatment both medically and 
surgically. The recognition by the Roentgenograph of a scorbutus 
which shows itself under the periosteum of the hip is especially 
valuable, as it saves the infant from the excruciating pain which 



102 THE ROENTGEN RAY IN PEDIATRICS. 

movement of any kind produces. It tells the surgeon that he is not 
dealing with a case of osteomyelitis or of tuberculosis, or possibly 
of a number of other infections, and enables him to avoid the neces- 
sary and painful manipulations which he would otherwise employ in 
determining whether the hip was affected. The same reasoning 
can be carried out when the other joints are affected. I would 
especially add that the differentiation of the enlarged wrist of scor- 
butus from that of rhachitis, and also from syphilis, by the Roentgen 
method is of the greatest diagnostic value and can be accomplished 
without harm to the infant. Again, the differentiation from a 
possible fracture is made with certainty and without pain, or a sus- 
pected separation or break in the region of the epiphysis. In some 
cases most serious mistakes have been avoided by the use of the 
Roentgen ray. Various operative procedures, and even amputa- 
tion of the thigh for sarcoma, have been given up because the ray 
has shown that the surgeon was not dealing with a sarcoma, but with 
a large organized subperiosteal effusion which simulated sarcoma. 
In some of these cases the tissues were found to be enormously 
infiltrated and hardened so that the tissue of the thigh assumed the 
appearance of a new growth. Instances of this class, which are only 
examples of what may occur in any part of the osseous system, 
have come under my notice quite a number of times, and in these 
cases after the differential diagnosis by the Roentgen method had 
been made the infants rapidly recovered under no other treatment 
than the prompt and free administration of orange juice. 

Plate 76, Fig. 2, shows the photograph of a girl eleven months 
old with scorbutus. Note the enlargement of both femora, espe- 
cially the upper part of the left femur. The disease had been going 
on for some months and the diagnosis of sarcoma was made at 
a consultation of surgeons. The infant was extremely pale and 
there was oedema of the feet and lower legs, with extreme tenderness 
on pressure of the hips, knee§, and ankles. The upper part of the 



DISEASES OF NUTRITION. 103 

left thigh showed a diffuse hard mass involving all the tissues. There 
was no fluctuation even on deep palpation. There was a rapid re- 
covery after the administration of orange juice. 

Fig. 1 represents a Roentgenograph of this case, and should be 
compared with Plates 163 and 164, Division IX, sarcoma of the 
thigh. The swelling and lack of clear definition of the muscles of 
both thighs is marked, and the irregular toothed appearance of the 
diaphyseal and in some places epiphyseal outline is accentuated. 
Note the roughened appearance of the zone of proliferation in 
contradistinction to the smooth-edged zones in Plate 75, infantile 
atrophy. 

Plate 77 represents the same case in a late stage and shows 
the organization of the clot considerably advanced. The thickened 
periosteum and the line of hemorrhage can easily be distinguished 
in the femora and in the tibiae. The epiphyses are irregular and the 
picture shows us that rhachitis is also present. Note here also the 
absolute dissimilarity of these epiphyses and zones of proliferation 
from what is seen in the case of infantile atrophy, Plate 75. 

Plate 78 represents the Roentgenograph of the leg of an 
Infant six months old. There is considerable involvement of the 
soft parts of the thigh, and the subperiosteal hemorrhage is easily 
followed along the whole length of the shaft of the femur. The 
extent of the hemorrhage along the line of the tibia is even more 
marked than in the femur. There is no especial change in the shaft 
of the bone, but the zone of proliferation is somewhat irregular. 

Plate 79 represents the same subject as Plate 78. 

Plate 80 shows an infant two months old. The infant was 
normal at birth, and had always been fed from the breast. The 
parents were healthy, and the mother apparently well at the time of 
nursing. The swelling and tenderness first appeared in the right arm 
and then involved the lower extremities. The left arm was slightly 
affected. The infant seemed to have considerable pain. It showed 



104 THE ROENTGEN RAY IN PEDIATRICS. 

evidence of no other disease. There was marked thickening of the 

periosteum of both lower extremities ; this condition is shown in the 

Roentgenograph. 

RHACHITIS 

The condition which in diseases of nutrition plays the greatest 
role, in that we find it associated with a large number of other dis- 
eases, is rhachitis. It is chiefly characterized by a local or a general 
disturbance of the normal process of ossification, but exactly how the 
hygienic and dietetic causes, which are supposed to produce these 
osseous changes, accomplish their results is still unknown. The uni- 
form and definite changes in the bones in rhachitis lead us to con- 
sider it a disease by itself, and one which, although connected with 
nutrition, is not wholly a form of malnutrition. The pathologic 
lesions of rhachitis are represented chiefly in the bones and occur 
during the period in which the normal processes of ossification are 
most active, that is, during the first year and the first part of the 
second year of life. The normal growth of bone depends upon three 
conditions : (a) Multiplication of cartilage cells in definite lines, (6) 
followed by calcification of the intercellular spaces for the entrance 
of blood-vessels with specific absorption of tissue, and (c) finally the 
concentric deposition of bone within the medullary spaces. The 
bones grow in length by the production of bone-tissue in the carti- 
lage towards the epiphysis and the diaphysis, and in thickness by 
the growth of bone from the inner layer of the periosteum. At the 
same time the medullary canal is enlarged in proportion to the 
growth of the bone by the absorption of its inner layer. These 
processes progress in definite order and in clearly defined zones. 

In rhachitis the chief microscopic features are the changes which 
occur in the zones of growth and the asymmetrical character of the 
proliferative processes. The cartilaginous and subperiosteal cell- 
growth which produces ossification goes on with increased rapidity 
and in an irregular manner both between the epiphysis and the 



DISEASES OF NUTRITION. 105 

diaphysis and beneath the periosteum. If we examine microscopi- 
cally the region between the epiphysis and the diaphysis, usually 
called the zone of proliferation, we find that the cartilaginous cells 
are not regularly arranged in rows around a definite zone in advance 
of the ring of ossification, as in normal tissue. On the contrary 
there is an irregular heaping up of cartilaginous cells, sometimes in 
rows, sometimes not, covering an ill-defined irregular area. This 
zone of proliferation also, instead of being narrow and sharply de- 
fined, is quite lacking in uniformity. It presents a broad, reddish- 
gray appearance, with marked thickening and hyperemia. The 
medullary spaces are much more vascular than normal, and are so 
increased in area as to extend into the zone of calcification, and 
sometimes through it. The deposit of bone-tissue within these 
spaces is, however, either absent or very irregular, and is for the 
most part replaced by a soft, friable substance, consisting of a 
bone-tissue that is very lacking in lime salts, with cells of various 
kinds embedded in a fibrillated ground-substance. This tissue is 
called "osteoid," and is similar to that formed by osteoblasts. 

In the region of ossification (ends of diaphyses and epiphyses) 
there is microscopically a pronounced increase of blood-vessels and 
cartilage-cells, with lengthening of cell columns, and disturbance of 
calcification of the intercellular substance. Calcification, if present, 
may be isolated in the region of the proliferating cartilaginous cells, 
or may be altogether absent over considerable areas. The subperios- 
teal layer of cells, which is normally thin and scarcely noticeable 
macroscopically, becomes hypersemic and thickened with an appear- 
ance similar to that of spleen-pulp. Beneath this periosteum is also 
to be found the " osteoid" tissue seen in the zones of proliferation. 

The medulla of the bone is more hyperaemic even than normal. 
Its tissue is rich in cells, and, like the fetal medulla, contains dilated 
vessels and fat. The intercellular substance may show mucoid 
degeneration or even be of fluid consistency. In such a condition 



1()0 THE ROENTGEN RAY IN PEDIATRICS. 

it does not seem that lime is dissolved from the bone-tissue by the 
blood, but that it is the resorption of such bone that is the important 
factor in the process. Resorption at the age at which rhachitis 
occurs is normal. Pimmes, especially, believes that resorption in 
rhachitis is not increased. Muller and Yirchow seem to hold the 
same views, while Kassowitz and Ziegler think it is increased. Clin- 
ically, certain extremely rapid cases of softening seem to show 
increased resorption (Vierordt). Ordinarily, with a resorption not 
oreatly increased, the formation of fresh bone containing but little 
lime results in loss of strength. In the skull, in some places, absorp- 
tion predominates (occiput) ; in other cases accretion of osteoid tis- 
sues (frontal and parietal eminences) . Deficient bone-growth simply 
determines open fontanelles. In convalescence lime is deposited in 
the previously limeless osteoid tissue, and the result is a thick and 
heavy bone. In fractures at this period callus-formation is excessive. 
An excessive proliferation of cells in the inner layers of the 
periosteum, the irregular calcification which occurs about them, 
and the absence of uniformity in the elaboration of the structure of 
the bone, produce an irregular, spongy bone-tissue instead of the 
compact lamellated tissue which is so necessary for the uniformity 
of the structure. The increased cell-growth between the epiphysis 
and the diaphysis produces the peculiar knobby swellings which are 
characteristic of rhachitis. At the same time the medullary cavity 
increases rapidly in size, and the inner layers of the bone become 
spongy. The result of these processes is to diminish the solidity of 
the bones so that they cannot resist the strain of the muscles or 
outside pressure. After a time the rhachitic process may stop and 
I lie bones may assume a more normal character. The porous bone- 
I issue becomes compact, and even unnaturally dense, so that in 
Liter childhood the rhachitic bone is unusually hard, like ivory, a 
condition noticed by those who have to operate on these bones. 

Fig. 1 represents a section of a normal bone taken from an 



DISEASES OF NUTRITION. 



107 



infant, and shows the normal zone of proliferation (Z. P.) between 
the epiphysis and the diaphysis. 

Fig. 2 represents a section of a rhachitic bone, and shows the 
broad, irregular, and abnormal zone of proliferation (Z. P.). 




Z.P. 



• HI 





Z.P. 



Fig. 1. — Normal bone: Z.P., zone of proliferation. Fig. 2. — Rhachitic bone: Z. P., zone of proliferation. 



The clinical diagnosis of rhachitis from diseases which may sim- 
ulate it need not be fully stated here. A few words, however, may 
aid us in making the best use of our Roentgen picture. In chon- 
drodystrophia foetalis the trunk is normal while the extremities are 
short and deformed. The enlargements of the ends of the long bones 
are due to overgrowth of the periosteum, instead of to changes in the 
epiphyseal cartilage, and the zone of proliferation is narrower than 
in rhachitis. In rhachitis there is an absence of the disproportion 
between the trunk and the limbs which is seen in chondrodystrophia 
foetalis. In chondrodystrophia foetalis also the epiphyseal lines instead 
of being irregular are straight, although much narrowed, and the 
shafts of the bones are often thick and striated. The characteristic 
symptoms of osteomalacia, a very rare disease in childhood, do not 



108 THE ROENTGEN RAY IN PEDIATRICS. 

appear in such marked degree and sequence as in rhachitis. Also in 
osteomalacia the lack of lime salts is shown by the degree of the den- 
si tv, and is usually well marked, and the deformities of the shafts of 
the bone are characterized by bending rather than by sharp curves. 

The differential diagnosis by the Roentgen ray is quite distinct 
and characteristic, and according to Osgood may be summarized as 
follows: In rhachitis there is great irregularit}^ of the epiphyseal 
lines with hyperplasia of the osteoid tissue and hypertrophy of the 
epiphyseal cartilage. These pathologic changes usually give the 
appearance of a great disproportion between the bony epiphysis 
and the epiplryseal end of the diaphysis. The curves in the shafts 
of the bones are often sharp. In chonclrodystrophia fcetalis and osteo- 
malacia the abnormal densities are seen most often to involve the 
joints, although the appearances in the adjacent bones are sometimes 
quite characteristic. They represent the poorly organized condi- 
tion of ill-nourished bone with a deficiency of lime salts. If foci 
(areas of definite necrosis) appear they are prone to involve the 
epiphyses. In osteomyelitis the abnormal densities are to be seen 
in the diaphyses and are generally due to irregular necrotic areas, 
with or without sequestra. There is usually no lessening of the 
densities of the involved bone or surrounding bones. 

The changes in the osseous system due to rhachitis are detected 
by the Roentgen method of examination before it is possible to do 
so by the clinical examination. The primary pathologic changes in 
rhachitis occur in the parts in which new bone formation takes place, 
the periosteum and epiphyses, and these can be classified for the pur- 
pose of Roentgen study and description as follows: 

The epiphysis and zone of proliferation. 
The outline of the cortex and periosteum. 
The medullary canal. 
The general structure of the bone. 



DISEASES OF NUTRITION. 109 

The changes in the bones of rhachitis are varied, although 
characteristic of the condition. 

There are some cases in which at any age from birth to puberty 
marked disturbances of the zone of proliferation take place and, 
though the case may not be recognized pathologically, yet clini- 
cally it presents the picture of a severe degree of rhachitis. We 
often find by examination that the epiphyses of all the bones are 
delayed in ossification, that they are smaller than they should 
be for the given age, and that there is such a lack of inorganic 
material in the bone that it gives an increased radiability. The zone 
of proliferation is a great deal wider than normal, with irregular 
deposits of bone on the epiphyseal side, so that we get a " toothed 
appearance" of the diaphysis with a degree of radiability in the 
zone of proliferation which is more like that of cartilage than bone. 
There is usually also a definite thickening of the periosteum. The 
changes in the bone are a thinning of the cortex, with an irregular 
deposit of bone-cells of irregular outline, an increase of the medul- 
lary cavity, and a marked re-arrangement of the bone structure. 
These changes go on to such an extent that cystic formation of the 
bone at times becomes apparent. Marked deformities of the osseous 
system may not always be present, but sooner or later, according 
to the activity of the child and the progress of the disease, deformi- 
ties of the bones take place, so that we get the characteristic bowing 
which is so marked clinically. Plate 87 illustrates what has just 
been said. In this plate it is to be noticed that the substance 
of the bone is greater on the concave than on the convex side. This 
is usually seen in the middle of the bone, and the medullary cavity 
of these cases often shows areas of increased radiability and appar- 
ently of cystic formation. This appearance is caused by areas filled 
with cartilage or osteoid tissue which has not calcified. 

Fracture, partial or complete, may be seen in any of the bones, 
and very little tendency towards callus formation, although appar- 



110 THE ROENTGEN RAY IN PEDIATRICS. 

ently enough to make the bone more or less solid (Plate 82). At 
points where the strain becomes great, as the deformity increases, 
an effort is made on the part of nature to prevent the bone giving 
way at this point by the laying down of new bone-cells, which are 
readily recognized by a more definite re-arrangement of the struc- 
ture of the bone (Wolff's Law, Plate 84). This is common in the 
lower third of the femur and the tibia in cases where there is clini- 
cally knock-knee or bow-leg. 

There are other cases which show a delayed ossification, a 
marked increase of the bones in size with no great change in the 
zone of proliferation, and in addition to this marked deformity. 
Clinically these cases show an enlargement of the epiphyses and of 
the diaphyses, but the bones generally show a more definite change 
in their structure. The outline may be irregular, very seldom the 
periosteum is thickened, and the cortex is thin or very little laid 
down. There is a marked increase of the medullary canal, with a 
definite change of the structure of the bone and a coarse re-arrange- 
ment of bone trabecule. The epiphyses in these cases are charac- 
terized by symmetrical enlargement of the diaphyses and with no 
apparent changes in the zone of proliferation. 

According to George these types of rhachitis from a clinical 
point of view are not distinguishable, but from a Roentgen point of 
view are quite evident. 

Plate 81 shows a very early stage of rhachitis in a child three 
years old. The shafts of the femora are comparatively normal in 
structure and in size. If, however, we compare this picture with the 
anatomic conditions seen in Plate 13, a normal child of three years, 
it will be noticed that the zone of proliferation is beginning to show 
a disturbance by its toothed and irregular appearance. The epi- 
physeal cartilage is also seen to be broader than normal, and this is 
seen to be still more evident if we compare this zone of proliferation 
with that of the case of infantile atrophy shown in Plate 75. 



DISEASES OF NUTRITION. Ill 

Plate 82 shows the characteristics of a typical case of rhachitis 
in the leg of a child two years old. The periosteum is thickened 
in several places. There is an irregular deposit of the cortex of 
the bone, especially at the upper ends of the tibia and fibula. The 
normal striation of the substance of the bone has been replaced by an 
irregular formation of the bone, showing itself by the jagged edges 
of the distal ends of the femur and tibia and of the epiphyseal line. 
There is a spontaneous fracture in the lower part of the femur. 
There is a deficiency of lime salts shown in both shafts and epiphyses, 
the latter being surrounded by normal epiphyseal cartilage. 

Plate 83 shows a boy seven years old with typical rhachitis. 
Fig. 1 represents the typical rhachitic position in sitting, and the 
prominent abdomen, enlarged wrists, knees, and ankles so common 
in rhachitis. 

Fig. 2 is a front view and Fig. 3 a side view of the same case. 

Plate 84 represents the Roentgenograph of the same subject 
shown in Plate 83. This plate shows some of the earlier mani- 
festations of rhachitis. There is a somewhat more marked bowing 
of the tibia and fibula, due to superincumbent weight, than would 
be expected from the slight alteration of structure presented in 
the bones. The diaphyses of both tibia and fibula are enlarged as 
compared with their shafts. The cortical bone is thicker on the con- 
cave side of the shaft at the part where the deformity is greatest, 
which is in accordance with Wolff's law. The structure of the bone 
is considerably coarser than normal, especially in the diaphyses. 
The epiphyses are all fairly well defined. There is very little disturb- 
ance of the zone of proliferation, which shows a lessened deposit of 
lime and increased radiability. 

Plate 85 represents a typical case of advanced rhachitis in a boy 
ten years old. The bones are increased in size and in thickness. 
The large amount of newly-formed bone and the decreased radia- 



112 THE ROENTGEN RAY IN PEDIATRICS. 

bility, especially at the ends of the bones, are in striking contrast 
with the lessened radiability of the shafts with their areas of 
irregular formation of bone and their lack of lime salts. Note 
the areas of thickened periosteum on both tibiae, and the decided 
thickening of the cortex on the curved sides of the bones in com- 
parison with the convex sides. 

Plate 86, Fig. 2, represents the photograph of a boy seven years 
old, showing especially an extreme bowing of the lower part of the 
tibia and fibula. 

The Roentgenograph, Fig. 1, shows a marked coxa vara with 
deformity of the pelvis. There is marked symmetrical increase in the 
size of the bones. The upper parts of the bones show a heavy deposit 
of cortical bone, especially on the concave side, and are also marked 
by increased radiability. There is a marked irregularity and an 
indefinite deposit of the lime salts, a condition which frequently 
occurs in rhachitis and which results in an increase of radiability in 
certain areas, especially in the lower parts of the femora and in the 
marrow. There is some disturbance of the zone of proliferation 
shown by the cortical bone being laid down in a somewhat irregular 
manner. The leader points to a needle which was accidentally dis- 
covered in the soft parts. 

Plate 87, Fig. 1, shows the photograph of a boy three years old 
with a protuberant abdomen, knock-knee, and enlargement of the 
ankle-joints. 

The Roentgenograph, Fig. 2, of the same case shows a thinning 
of the cortex with increase of the medullary canal, a lack of lime 
salts and a consequent increased radiability. 

Rhachitis of Adolescence. — At about the age of puberty in 
certain individuals the physical signs of rhachitis, with the excep- 
tion of a lesser degree of epiphyseal enlargement, occur, and in these 
cases albuminuria is usually present. Cases of this class are desig- 



DISEASES OF NUTRITION. 113 

nated as the rhachitis of adolescence or late rhachitis. The disease 
is a rather common one and is characterized clinically by genu val- 
gum or varum, scoliosis, or nothing more marked than enlarge- 
ment of the epiphyses and of the diaphyses. Some authorities claim 
that this condition is the forerunner of osteomalacia. The charac- 
teristics of the disease are: 

The outline of the bone is usually normal. 

The size of the bone is usually normal. 

The epiphyses are well developed. 

The zone of proliferation presents more of a change than is 
present in normal epiphyseal cartilage. 

The diaphyses are toothed as well as the epiphyses and show an 
irregular deposit of bone-cells. 

Plate 88 shows the hands of two boys, each thirteen years old. 
Fig. 2 is normal for the given age while Fig. 1 shows the condition of 
the rhachitis of adolescence. By comparison with the normal hand, 
Fig. 2, it is noticeable that there is a characteristic increased radia- 
bility. The medulla is apparently normal, excepting for its increased 
radiability. The structure of the bone is coarser, but no more regu- 
larly deposited than that seen in the rhachitis of an earlier period, 
having generally coarser yet regular bone trabecule. 

Plate 89 shows the hand of a boy twelve years old with the 
rhachitis of adolescence. The bones show a thickening of the peri- 
osteum along the phalanges, and a slightly greater toothed and 
ragged appearance of the zone of proliferation than in the case of 
the same disease just spoken of (Plate 88). It also shows more 
cortical substance than in the previous case. 

Intra-uterine Rhachitis (Fetal Rhachitis). — My opinion in regard 
to this condition has been stated on page 90, Division III. 



PLATE 74. 
OSTEOMALACIA. 

Girl, age 7 years. (Reduced 52$%.) 

Fig. 1. A Roentgenograph of the Pelvis and Legs. 

A. Points to the upper third of the right femur. 

B. Points to the coarse bone structure in the upper 

part of the left femur. Just below this is a 
marked bowing with evidence of a previous 
fracture, now united. The bones in general 
show an irregular deposit of cortical bone. 

Fig. 2. A Photograph of the Same Subject. 

Showing considerable bowing of the upper third of 
the left femur. 



FIG. 1 



Plate 74 




PLATE 75. 

INFANTILE ATROPHY. 

Fig. 1. Photograph of an Infant, Age 12 Months. 

Fig. 2. A Roentgenograph of the Same Subject. 

Shows the clear-cut outline of the bones. The texture of 
the bones shows nothing that would be called abnormal. 



fig. 2. Plate 75 




FIG. 1. 








PLATE 76. 
INFANTILE SCORBUTUS. 

Girl, age 11 months. (Reduced 46%.) (Same subject as Plate 77.) 

Fig. 1. A Roentgenograph of the Lower Extremities. 

A. Slightly thickened cortex. 

B. Slightly thickened periosteum. 

C and D. Areas of infiltrated tissue. 

Fig. 2. A Photograph of the Same Subject. 



FIG. 1 



Pjlate 76 




PLATE 77. 
INFANTILE SCORBUTUS. 

Girl, age 11 months. (Reduced 40%.) (Same subject as Plate 76.) 

^4. Organizing clot following hemorrhage. 
B. Thickened periosteum. 

The epiphyses of the knees and ankles are present but show 
less density than normal. 

Zone of proliferation irregular. 



Plate 77 





PLATE 78. 
INFANTILE SCORBUTUS. 

Age 6 months. (Reduced 12%.) (Same subject as Plate 79.) 

A. Thickened periosteum. 

B. Organizing clot. 

C. Hematoma of the muscles of the thigh. 







Plate 78 



/ 



PLATE 79. 
INFANTILE SCORBUTUS. 

(Reduced 51%.) (Same subject as Plate 78.) 

A. Thickened periosteum. 

B. Organizing clot. 

C. Irregular zone of proliferation. 

D. Hematoma of the muscles of the thigh. 



PliATTC 79 



l 




PLATE 80. 
INFANTILE SCORBUTUS. 

Age 2 months. (Life size.) 

A and B. Thickened periosteum. 
C and D. Infiltrated muscle. 



Plate 80 




i 




PLATE 81. 
EARLY RHACHITIS. 

Age 3 years. (Reduced 28%.) 

The arrow points towards an irregular zone of proliferation. 



Plate 81 




PLATE 82. 
EARLY RHACHITIS. 

Age 2 years. (Reduced 12%.) 

A. Slightly thickened periosteum. 

B. Irregularly ossified cortex. 

C. Partial fracture of lower third of femur. 



Plate 82 





PLATE S3. 
RHACHITIS. 

(Same subject as Plate 84.) Boy, age 7 years. 

Fig. 1. Typical Picture when Sitting. 

Fig. 2. Bowing of Right Arm, Flat-foot, Relaxation of 
Knee-joint. 

Fig. 3. Prominent Abdomen, Enlarged Epiphyses. 



FIG. 1. 



Plate 83 




FIG. 2. 



FIG 3. 





PLATE 84. 
EARLY RHACHITIS. 

Boy, age 7 years. (Reduced 16i%.) (Same subject as Plate 83.) 

A. Thickened cortex (Wolff's law). 

B. Absorption of lime salts of the ciiaphysis of the tibia. 

C. Decreased density. 




Plate 84 



PLATE 85. 
ADVANCED RHACHITIS. 

Boy, age 10 years. (Reduced 50%.) 

Great disturbance of the structure of the bones. 
Thickened cortex of concave sides of the tibiae. 



Pjlate 85 




PLATE 86. 
MARKED RHACHITIS. 

Boy, age 7 years. (Reduced 33£%.) 

Fig. 1. — Pelvis and Femora. 

The Roentgenograph shows especially the absorption of the 
lime salts in the upper epiphysis of the femur, with marked irreg- 
ularity in the structure of the bone, and a marked coxa vara. 
Note the greatly decreased density in the lower part of the fem- 
ora, the beak-shaped outline of the cavity of the pelvis, and the 
deformed ilia with a great irregularity of the structure of the bone. 

A. Points to heavy deposit of cortical bone. 

The arrow points towards a foreign body, a needle which 
was accidentally found at the examination. 

Fig. 2. Photograph of the Same Subject. 

Shows a marked deformity from bowing of the legs. 



FIG. 1. 



Plate 86 




PLATE 87. 

Boy, age 3 years. (Reduced 25%.) 

Fig. 1. Photograph Showing the Protuberant Abdomen, 
Knock-knee, and Flat-foot. 

Fig. 2. Roentgenograph of the Same Subject. 

A. Marks the thickened periosteum. 

B. Points toward the very irregular epiphyseal line. 

C. Thickened periosteum. 



Plate 87 





FIG. 2. 



I 



PLATE 88. 
RHACHITIS OF ADOLESCENCE. 

Hands of two boys, each 13 years old. (Reduced 261%.) 

Fig. 1. Rhachitic Hand. 

The upper arrow points towards a general deviation from 
the normal structure of the bone. This is evident in the whole 
hand. 

The lower arrow points to the irregular epiphyseal line of 
the lower epiphysis of the radius. 

Fig. 2. Normal Hand. 



Plate 88 





PLATE 89. 
RHACHITIS OF ADOLESCENCE. 

Age 12 years. (Reduced 7|%.) 

A. Shows lessened density of cortex. 

B. Slight thickening of periosteum. 

C. Marked by irregular and broad zone of proliferation show- 

ing the lack of bone-forming cells and an increase of the 
cartilage cells. 

D. Sesamoid bone. 



Pirate 89 




Division V 

DISEASES OF THE HEAD AND SPINE 
HEAD 

There are comparatively few abnormal conditions of the head 
which can be satisfactorily recognized by the Roentgen method. 
In tumors of the brain, where there is a reconstruction of the tissues 
by new tissues being added, or where there is less tissue than normal, 
a picture representing the tumor can at times be demonstrated. 
Where, however, there is the same amount of tissue as is in the nor- 
mal brain, a very small amount of information can be obtained by 
means of the Roentgen ray. We at times have been able to detect 
a tumor of the brain in early life, and have had under our care at 
the Children's Hospital a case of this kind in which the tumor was 
located by means of the Roentgen ray. Certain results of trauma- 
tism, such as fractures, play an important role, and certain infec- 
tions of the jaws and surrounding tissues can often be diagnosticated 
definitely only by means of the Roentgen ray. Of great and increas- 
ing value is the aid given by Roentgen films of the teeth. By their 
assistance in the diagnosis of either variations or anomalies of the 
teeth, the orthodontist is enabled to carry out his work with a pre- 
cision which before the Roentgen ray could be applied to this class 
of cases was unknown. As in the study of other parts of the body, 
so it is with the head, that to understand diseased conditions and to 
intelligently diagnosticate and treat them, a knowledge of the nor- 
mal conditions is essential. We must be able to say whether the 
different sinuses, frontal, ethmoidal or sphenoidal, are in a normal 
or abnormal condition. A suspected fracture of the skull can be 
often diagnosticated only by means of the Roentgen method. 

As an example of this, Plate 90 shows a fracture of the skull 

115 



116 THE ROENTGEN RAY IN PEDIATRICS. 

in a boy thirteen years old. This fracture was not recognized clini- 
cally until a Roentgenograph was taken. 

Plate 91 shows an inflammatory process indicating ethmoiditis 
in a child three years old. This plate also shows a full set of normal 
temporary teeth. 

Plate 92 shows how important it is to have the temporary 
teeth cared for. In this case a lack of care of the mouth and teeth 
resulted in caries and suppuration of the roots of the teeth and 
finally an osteomyelitis. This class of cases arises usually from 
neglect, and oftener from this cause than from traumatism. The 
legend of this plate shows what extensive lesions may result from 
osteomyelitis of the jaw. 

The anomalous conditions which may arise in connection with 
the teeth in early life are very numerous. A few of these, however, 
will be sufficient to show how important it is to recognize such condi- 
tions when present, and how impossible it is to definitely localize, 
diagnosticate and make use of this exact knowledge without the aid 
of the Roentgen ray. 

Plates 93 and 94 show the sides of the head in a boy thirteen 
years old. The value of obtaining an exact knowledge of the exist- 
ence and position of an unerupted tooth by means of the Roentgen 
method is obvious. These plates show the second lower bicuspids 
wedged between the first and second molars. Under intelligent 
treatment by mechanical means, which could be carried out when 
once the abnormal position of the teeth was determined, the abnor- 
mality was corrected. 

Plate 93 shows the left side of the skull. In the upper jaw the 
teeth are very well defined. The central and lateral incisors can 
readily be seen. The permanent cuspid does not show very clearly 
but its eruption at a later period proved its existence. The un- 
erupted first and second bicuspids partly calcified can be seen 



DISEASES OF THE HEAD AND SPINE. 117 

directly above the temporary molar, the roots of which have been 
absorbed, leaving them about to be exfoliated. The first permanent 
molar can be seen completely formed, while the roots of the second 
molar, unerupted, are but partly calcified. The third molar does not 
show much evidence of being present, although there seems to be a 
slight outlining of the crypt in which its formative organ lies and 
the beginning of calcification of the tips of the cusps. 

In the lower jaw the crypt of the third molar is fairly well 
defined and four points of calcification can be seen. The second 
molar shows clearly. The roots are partly formed with wide openings, 
large pulp canals and large pulp chambers. A comparatively small 
amount of caries at this period of development might have involved 
the pulp, and its loss through irritation would be more serious to the 
future usefulness of the tooth than after the entire calcification of 
the tooth had been completed. The first molar shows the complete 
calcification of the roots with much smaller pulp canals and pulp 
chambers. This same decrease of size of canals and pulp chambers 
will take place in the second molar during its continued calcification. 

Anterior to the first molar can be seen the reason for the Roent- 
gen examination. Here lies the unerupted second bicuspid tooth, 
held in this position by the forward growth of the first and second 
molars, due to the premature loss of the second temporary molar, 
leaving a space of one-eighth of an inch between the crown of the 
first permanent molar and that of the first bicuspid. The root is 
but partly formed and the tooth would readily erupt if it had 
sufficient space. This proved to be true later when space had 
been made by lengthening and widening the lower arch. The same 
condition existed on the right side of the jaw, which is shown in 
Plate 94. 

Anterior to this first bicuspid is a cuspid which is just erupting. 
Anterior to this tooth the teeth are indistinct. A Roentgenograph 



118 THE ROENTGEN RAY IN PEDIATRICS. 

of this size is not satisfactory for determining the position or con- 
dition of the individual teeth anterior to the second bicuspids. A 
small film placed inside the mouth gives a much clearer view of the 
point of interest, and by this means we are not confused by the 
teeth on the other side of the jaw. 

Plate 95 shows the erupted first permanent molars and some 
of the unerupted teeth in a boy eight years of age. 

In the upper jaw the teeth are shown to be in an abnormal 
condition of calcification and eruption. The picture shows the 
right central incisor unerupted and the root partly calcified. The 
permanent lateral incisor has just appeared through the gum 
and its root is also partly calcified. The permanent cuspid lies 
posterior to the lateral incisor, which has just appeared through 
the gum, and its root is only partly calcified. The first bicuspid 
is only partly calcified and its root not entirely formed. The 
space between this tooth and the lateral incisor is not sufficient to 
allow the cuspid to erupt in a normal position. Posterior to the 
first bicuspid root lies the second bicuspid, with only its crown cal- 
cified. Below are the roots partly absorbed and what is left of the 
carious crown of the second temporary molar. The first perma- 
nent molar lies posterior to this tooth and appears well formed and 
fully erupted. Posterior to the roots of this tooth lies the second 
permanent molar, with only its crown formed. There are no signs 
whatever of the third molars in either the upper or lower jaw. 

In the lower jaw from behind forward is the second molar in its 
crypt with its crown calcified. Next in front is the first molar fully 
erupted, with the apices of its roots not as yet calcified. Next in 
front of this is the second bicuspid in its crypt with the calcification 
of its root not begun. Above this is the carious crown of the second 
temporary molar. The next anterior tooth is the first bicuspid just 
showing its crown through the gum. Its root is but partly formed. 



DISEASES OF THE HEAD AND SPINE. 119 

Immediately above are the outlines of the teeth in the opposite side 
of the upper jaw, and they are not considered in this description. 
Next can be seen the form of the unerupted and partly formed cus- 
pid, the crown of the temporary cuspid lying above and a little in 
front. Its root is nearly absorbed. 

The inferior incisors have all erupted but are in malposition. 
This is not shown very clearly from this view. 

Supernumerary teeth play quite an important role in dentistry, 
since, although comparatively rare, they may occupy space needed 
for the proper position of the other teeth. 

Plates 96, 97, and 98 are examples of this kind and show the 
great value of Roentgen examination. 

Plate 96 shows the left side of the skull of a boy fifteen years 
old. The sinuses are well developed. The teeth are very well shown 
in the upper jaw, but in the lower jaw they are somewhat confused 
on account of the presence of the teeth on the opposite side. 

In the upper jaw the central and lateral incisors are fully erupted 
and the cuspid almost in position. Just above the lateral incisor is a 
supernumerary tooth unerupted. The first and second bicuspids are 
normal and fully erupted. The first and second molars are clearly 
defined. The third molar shows beautifully in its crypt, with only 
the crown calcified in accordance with the boy's age. The lower 
third molar shows a similar condition. The second and first molar 
roots do not show clearly, nor do those of the second and first bicus- 
pids, although the crowns of the latter are well marked and the 
pulp canals and chambers can be traced. Anterior to the first bicus- 
pid the teeth are not distinct enough to allow of any accurate de- 
scription. 

Plates 97 and 98 show the right and left sides of the skull of a 
girl fourteen years old. The sinuses are normal and very large in 
both plates. 



120 THE ROENTGEN RAY IN PEDIATRICS. 

The temporal bones and the glenoid fossae, in which lie the 
condyles of the inferior maxilla, are clearly defined. 

The right side of the head shows the superior cuspid retained in 
its alveolus in a flat position (this is shown better in the film print 
below). In the film print (looking out from the inside of the mouth) 
the superior right cuspid lies in the centre. Back and to the right 
of the cuspid and partly obscuring it is the first bicuspid. Then 
come the second bicuspid and the first molar, the roots of the 
latter not being so clearly defined as those of the cuspid. To the 
left of the cuspid can be seen three incisor teeth. The one to the 
extreme left is the right central incisor, and next to the right of this 
tooth is a supernumerary tooth, in the palatal aspect of the central 
and lateral incisors the next tooth to the right. 

There is nothing of interest in the plate until we come to the 
region of the superior second molar. This tooth is indicated by the 
great density of the first molar and the tooth which is a super- 
numerary in the palatal aspect. Back and above the second molar is 
the partly calcified and unerupted third molar. 

In the lower jaw from back to front the teeth are normal. 

Plate 98 shows the left side of the head. The superior cuspid 
is seen in a somewhat crowded position. The film below shows 
the tooth much more plainly. The left side of the mouth has the 
same anomalies as the right, with the exception of the lack of a 
supernumerary tooth in the second molar region. In the film the 
tooth, only part of which shows in the lower right-hand corner, is 
the left central incisor. The next tooth to the left is a supernumer- 
ary tooth partly obscured by the left lateral incisor. The partly 
formed third molar is unerupted, as is the case on the right side. 

Plate 99 illustrates the value of the Roentgen method of exami- 
nation in a number of cases. 

Figs. 1 and 2 represent the mouth of a child fourteen years 



DISEASES OF THE HEAD AND SPINE. 121 

of age. Fig. 1 (the left side) shows the absence of the second 
bicuspid (A). The accompanying Fig. 2 shows the opposite side 
of the mouth which also lacks the second bicuspid. The crown 
of the second temporary molar is still in place, although the 
absorption of the greater part of the root has taken place without 
the formation of the permanent teeth underneath it. 

Fig. 3 shows the mouth of a child thirteen years old with 
the absence of the second bicuspid. The temporary molar has 
remained in the mouth with no absorption of its roots. 

Fig. 4 shows an interesting picture with possibly a super- 
numerary tooth. It will be seen that the cuspid (B) lies in the 
upper left-hand portion of the picture; immediately beneath it 
is the lateral incisor (C), and immediately beneath the lateral 
incisor and a little in front of it is the crown of the temporary 
lateral incisor or possibly a supernumerary tooth (D). Lying 
directly back of the central tooth, which is the lowest tooth on 
the plate, lies a temporary cuspid (E) , and immediately above it 
is the permanent first bicuspid (F). Back of this temporary 
cuspid root lies the crown of the first temporary molar. It will 
be seen that the permanent central incisors are in malposition, as 
are also the lateral. 

Fig. 5 shows the superior cuspids lying in the palate directly 
behind the central incisors. It was found that the apices of their 
roots were in normal position. These teeth are now being moved 
into place. 

Fig. 6 shows the upper jaw of a girl nine years of age. The 
plate is read from right to left. In the right upper corner is seen 
the tip of the right permanent cuspid, and after this come the 
permanent central incisors. There is an entire absence of perma- 
nent lateral incisors in this jaw. The temporary left lateral incisor, 
next to the left central incisor, has its root almost entirely absorbed, 



122 THE ROENTGEN RAY IN PEDIATRICS. 

and above it is the permanent cuspid (H) somewhat rotated. 
Behind the temporary lateral incisor is the temporary cuspid (7), 
and behind this tooth are the first and second temporary molars. 
The angle at which the film was exposed does not allow the amount 
of absorption of the roots of these teeth to be shown, but the 
crowns of the first and second bicuspids (J and K) can be seen 
directly above them. 

Fig. 7 shows the mouth of a child eight years of age with the 
temporary cuspid and the first and second molars in place. Above 
these are the permanent teeth developing and erupting. This plate 
shows very clearly the absorption of the temporary teeth. 

Fig. 8 represents the mouth of a girl between eight and nine 
years of age. The picture shows the teeth of the left side of the 
upper jaw with the permanent central incisor well developed and 
the lateral incisor presenting an interesting feature. There seems 
to be a thickness of its roots about one-sixteenth of an inch from 
its apex, and also an apparent constriction of the root canal (L). 
The crown also seems to be misshapen, but this is due to a slight 
torsion or rotation of its root. The temporary cuspid (M ) is still 
in place with but little absorption of its root. Above this tooth 
and in front of it can be seen the crown of the permanent cuspid 
with its root partly formed and with a wide apical opening and a 
large root canal. Behind the crown of the first bicuspid below this 
tooth is the crown of the first temporary molar. 

Fig. 9 shows the mouth of a child ten years of age. The 
second temporary molar is still in place and the second bicuspid 
(N) is directly above it. This plate shows the undeveloped root 
of the first bicuspid, also the crown of the upper temporary cuspid 
(0) tilted back, and the permanent cuspid almost erupted. 

Fig. 10 shows the right side of the upper jaw of a girl between 
seven and eight years of age. The central incisor is well developed 



DISEASES OF THE HEAD AND SPINE. 123 

and the temporary lateral incisor is still in place, not absorbed 
but deflected forward by the erupting permanent cuspid (P) . The 
temporary cuspid (Q) shows its root partly absorbed. The first and 
second temporary molars have not been lost, but their roots are 
completely absorbed. The first and second bicuspids can be seen 
directly above them. The development of the roots of these teeth 
does not appear. 

Fig. 11 shows that with the exception of the tooth at the 
extreme left, which is the right upper central incisor, all of the 
other areas of density represent the temporary teeth. The areas 
above represent the permanent teeth, that is, the right upper 
cuspid (R) and the first and second bicuspids which are in the 
process of eruption. 

SPINE 

The spine is best described separately from the rest of the 
skeleton, as its position behind the sternum and the various organs 
not only interferes with a clear picture of other parts but also is 
liable to affect its own definition. It is, however, my intention to 
describe the spine and its diseases in a general way and only with 
the purpose of indicating what especial conditions can be practically 
shown by the Roentgen method. According to our experience in the 
various clinics of the Children's Hospital, where a very large num- 
ber of Roentgenographs are taken every year, the information 
obtained by the clinical examination of the spine rarely compares 
favorably with the condition disclosed by the Roentgen ray. At 
present, owing to the difficulty of the technic, it is not possible to 
take satisfactory Roentgenographs of the lateral views of the spine. 
Almost without exception our hospital subjects are taken with the 
back on the plate, since this is the position in which the pictures of 
the vertebrae are least interfered with by those of other parts of 
the body. It is important that the entire vertebral column should 



124 THE ROENTGEN RAY IN PEDIATRICS. 

in each case be looked over carefully, for in this way most valuable 
information can be obtained in regard to practical treatment. What 
we should determine in abnormal conditions of the spine is the dif- 
ferentiation of abnormalities which have occurred before birth 
during the process of development from post-natal traumatism 
and infection. The former class of cases, the prenatal, has already 
been described in Division III, Plate 41 (anomalous atlas and 
axis), Plates 42, 43 and 44 (spina bifida). I shall not attempt to 
describe the traumatic class of cases, as they are so closely con- 
nected with the work of the orthopedist, and comprise in themselves 
such a wide field of study, that they would require a special treatise 
to do them justice. The various degrees of so-called functional, 
better designated as inorganic, abnormalities of the spine, such as 
lordosis, kyphosis and scoliosis, arising from postural deformities, 
are readily diagnosticated by means of the Roentgen ray. Although 
the external clinical evidence of these conditions is of the greatest 
value in the hands of an expert in this branch of medicine, yet the 
readily obtained Roentgen picture is so valuable, instructive, and 
important, especially in complicated cases, that it is safer to make 
use of it, if for no other reason than that some unsuspected abnor- 
mality may be brought to light. It is worth while, therefore, to 
become familiar with the normal conditions of the spine, and to 
study its position, the texture of the vertebrae, the radiability indi- 
cating breaking down of one or more bodies, the condition of the 
intervertebral discs, and the relation of the transverse processes to 
the lines of the entire column. In this way also we can detect vari- 
ous degrees of curvature and rotation and recognize not only postural 
defects but actual lesions of the bone and cartilage. Keeping this 
idea in view I will refer you to Plate 23, which shows the normal 
spine at ten years. 

It cannot be too strongly emphasized that a recognition of 



DISEASES OF THE HEAD AND SPINE. 125 

abnormal conditions of the spine, as shown in the Roentgenograph of 
the vertebrae and cartilaginous discs, depends upon a precise knowl- 
edge of the various details shown in the pictures of such normal 
conditions. The finer diagnoses of diseased conditions are attained 
by the power to interpret the normal conditions in their various 
stages of development, as well as by the skilful differentiation of the 
densities where they are interfered with by the thoracic and abdom- 
inal organs. 

The diseases which can be diagnosticated in the spines of chil- 
dren are not very numerous. The various degrees of thickening and 
rigidity of the vertebrae, caused by hypertrophic and atrophic con- 
ditions, are as uncertain in their etiology as are the same conditions 
in the joints. They are indeed so rare in early life that they should 
not be dwelt upon to any great extent. Rhachitic conditions not 
uncommonly show themselves in the spine. There are a few specific 
infections which attack the spine, occasionally an osteomyelitis, but 
this is rare. The organism which plays the greatest role in the 
spinal infections of childhood is the bacillus of tubercle. The result 
of this infection in its chronic form is what is usually, though not 
advisedly, spoken of as Pott's disease. 

A few rules in connection with what we may expect to see and 
what we are to look for in the Roentgen examination of the spine 
may be of value to the student and to the general practitioner. Func- 
tional or inorganic lateral curvature is characterized by a single or 
double curve of comparatively slight degree and usually to the left in 
about 90 per cent, of all cases. In such cases the left shoulder is 
higher than the right. There is usually no rotation of the trans- 
verse processes which are seen equally well on either side of the 
spine. There are also transitional cases which are produced by such 
causes as congenital absence of the ribs, causing scoliosis. Again in 
this set of cases there are curvatures resulting from operations on the 



126 THE ROENTGEN RAY IN PEDIATRICS. 

thorax, notably for empyema. Plate 130, Division VI, is an example 
of this condition. In structural or organic curvatures the following 
conditions may be looked for: single curves, representing either 
kyphosis, scoliosis, or lordosis; and compound curves consisting of 
one or more curves in different parts of the spinal column with rota- 
tion in the opposite direction. There are also to be noted changes in 
the intervertebral discs and in the bodies of the vertebrae showing 
disturbance of normal structure and abnormal radiability. The 
pathologic condition may be a periostitis, osteitis or osteomyelitis, 
with the end results of breaking down of one or more bodies of the 
vertebrae. The non-tubercular infections are much more rare than 
the tubercular, which are very common, and of the tubercular 
class the chronic form is more common than the acute. Other con- 
ditions, such as osteomalacia, osteogenesis imperfecta, chondrodystro- 
phia fcetalis, and malignant growths, may sometimes also be present. 
Having once detected and located the part of the spine affected, 
note should be made of the amount of deformity or curves of the 
whole spine, the number of vertebrae diseased, the amount of bone 
involved, and the condition of the intervertebral, discs. The inter- 
vertebral discs when diseased usually show atrophy and they may 
seem to be nearer together than normal. 

Plate 100 shows the spine of a colored boy six years of age with 
rhachitis. The rhachitic process is in this instance in an early stage 
of change from the normal, and is especially seen in the transverse 
processes of the third lumbar vertebra, which are slightly increased 
in size and show, as does the ilium, a coarse arrangement of the 
structure of the bone. The radiability is increased throughout the 
lumbar vertebrae. There is no particular disturbance in the zone of 
proliferation. 

The non-tubercular infections of the spine, although rare, yet 
must be recognized and separated from the common tubercular 



DISEASES OF THE HEAD AND SPINE. 127 

infections. The most common form of the non-tubercular affections 
which can be studied by the Roentgen ray is osteomyelitis. An 
early diagnosis of osteomyelitis of the spine is difficult. In contra- 
distinction from tubercular there is a more localized infection of one 
body or partial destruction of the vertebrae. There is more prolifer- 
ation of tissue about the body of the vertebra and usually very little 
deviation of the spine. There is usually the history of an acute 
infection. 

Plate 101 shows the lesions of osteomyelitis of the spine in a 
girl four and a half years old. There is a destructive process with an 
effort at reconstruction of the second, third, and part of the fourth 
lumbar vertebrae. The body of the third lumbar vertebra is almost 
destroyed, especially on the right side. 

Tuberculosis of the spine locates itself almost exclusively in the 
bodies of the vertebrae, attacking primarily only the interior of the 
bodies and rarely their surface. This tubercular osteitis, when it 
has progressed sufficiently, causes collapse of the vertebral columns. 
The intervertebral cartilage is also often destroyed by the process, 
but the arches of the vertebrae are only in rare instances affected. 
Abscesses may form later in the midst of the broken-down tubercular 
bodies of the vertebrae and may be of varying size after they have 
broken through into the surrounding soft parts. Where the diseased 
condition is at all advanced the diagnosis by means of the Roentgen 
ray is easily made, but it is much more difficult in the very early or 
hyperaemic stage. As the process goes on, however, a larger area is 
involved and this will be seen in the bodies of the vertebrae, particu- 
larly in the spongy portion, as an area more or less definite and 
showing an increase of radiability. This means that the normal 
structure of the bone is changed, and that the ray passes more easily 
through the bone in this, the diseased portion, than through the 
other portions. If the process continues the area of disease becomes 



128 THE ROENTGEN RAY IN PEDIATRICS. 

larger, destruction of the bone takes place, and finally cheesy degen- 
eration of its centre goes on with still greater increase of radiability. 
Possibly a localized abscess of the bone may result. This too may be 
readily detected by its increased density. If the disease progresses 
we find softening, greater density of one or more bones, and a crush- 
ing together of the bodies. At this time in the history of the case 
the intervertebral cartilage has disintegrated and disappears. In 
regard to the formation of an abscess, the abscess may be first 
external, and second, internal, as a mediastinal abscess. Almost 
ever}^ case of tubercular infection of the spine will be seen to have 
an abscess. This condition can readily be differentiated by the ray. 
To be interpreted from the plate are : 

1. The external area of disease, shown in the plate by decreased 
radiability, usually limited to the diseased portions. 

2. The mediastinal as a definite area of increased density 
ballooning out and around the diseased portion. 

Plate 102 shows an absorption and fusion of the intervertebral 
cartilages of the third and fourth lumbar vertebrae. The destruction 
of a part of the left ilium is seen just above and outside of the acetab- 
ulum. The third and fourth vertebrse give evidence of necrosis, 
showing more destruction on the right side than on the left. There 
is an evident necrosis of the bone of the ilium, with abscess about 
the left hip- joint. There is decreased radiability of the femur on 
the left side. 

Plate 103 shows a tubercular process of the sacro-iliac joint, 
causing deformity of the pelvic line of the left side. There is also a 
marked increase in the radiability of the ilium, except where a dark 
rim denoting the boundary of the destructive process shows new 
bone formation and consequent decreased radiability. There is 
more or less destruction of the sacrum on the left side, and marked 
deformity of the pelvis resulting from the actual destruction of the 



DISEASES OF THE HEAD AND SPINE. 129 

sacroiliac joint. There is also an atrophy of quality of the acetab- 
ulum, as well as of the whole femur on the left side, as shown by the 
increased radiability, although there is no change in the size of the 
shaft. 

Plate 104 shows in the tenth dorsal vertebra the beginning of an 
absorption and a destruction with fusion of the body with the ninth 
dorsal vertebra. At about this point thickening of the tissue and 
the formation of an abscess are apparent in the Roentgenograph. 

Plate 105 is that of a child four years old and shows tubercular 
lesions of the spine. There is an absorption of the tenth, eleventh, 
and twelfth dorsal intervertebral cartilages to the right, with an 
apparent fusion of these bodies. At the tenth dorsal vertebra is 
seen the beginning of an absorption and a destruction with fusion of 
the body with the ninth dorsal vertebra on the left side. At this 
point also there is either breaking down of the neighboring tissues 
or the formation of an abscess, as is seen to the right in the Roent- 
genograph. 

Plate 106 gives a lateral view of the same subject, and shows 
that there is complete absorption of the twelfth dorsal and partial 
destruction of the eleventh dorsal vertebrae. It is well to compare 
this process, which is clean cut, with that shown in osteomyelitis, 
Plate 101. It will be noticed that the abdomen is rather prominent 
and that lordosis is present. 



PLATE 90. 

FRACTURE OF SKULL. 

Boy, age 13 years. (Reduced 39%.) 

A. Frontal sinus. 

B. Orbit. 

C. Sphenoidal sinus. 

D. Region of antrum. 

E. F, A fracture of the base of the skull. 



Plate 90 





* 




r 



PLATE 91. 
ETHMOIDITIS. 

Age 3 years (Reduced 12%.) 

A. Frontal sinus. 

B. Second lower temporary molar. 

C. Central and lateral upper incisors (not well denned). 

D. Permanent upper cuspid. 

E. Permanent second upper bicuspid. 

F. First permanent upper molar. 

G. First permanent lower molar. 
H. Inflammatory area (ethmoid). 

/. Orbit, 

The increased density shows the process of inflammation 
in the ethmoid bone, frontal sinus, and antrum. 



Plate 91 




PLATE 92, 
OSTEOMYELITIS OF LOWER JAW. 

Colored boy, age 12 years. (Life size.) 

A. Frontal sinus. 

B. Ethmoidal cells. 

C. Floor of the orbit. 

D. Antrum. 

E. Sphenoidal sinus. 

F. Left permanent upper central incisor. 

G. Left permanent upper lateral incisor. 
H. Left upper temporary cuspid. 

7. Permanent upper cuspid. 
/. First upper bicuspid (misplaced) . 
K. Second upper bicuspid. (Turned one quarter around and 

pointing backward.) 
L. First and second upper temporary molars. 
M. Second upper permanent molar. 

A tooth, a second lower molar, was found at a second 
operation in the soft tissues of the lower jaw, the sequestrum 
having been removed at the first operation. 



Plate 92 




PLATE 93. 
ANOMALOUS BICUSPIDS— LEFT SIDE OF HEAD. 

Boy, age 13 years. (Life size.) (Same subject as Plate 94.) 

A. Frontal sinus. 

B. Orbit. 

C. Sphenoidal sinus. 

D. Antrum. 

E. First and second upper temporary molars. 

F. Third permanent upper molar. 

(The cusps of this tooth are just beginning to show calci- 
fication). 

G. Crypt of third lower molar. 

H. First lower bicuspid (unerupted) . 
/. Second lower bicuspid (unerupted). 



Plate 93 




PLATE 94. 
ANOMALOUS LOWER BICUSPID— RIGHT SIDE OF HEAD. 

Boy, age 13 years. (Life size.) (Same subject as Plate 93.) 

A. Frontal sinus. 

B. Orbit. 

C. Sphenoidal sinus. 

D. Antrum. 

/. Unerupted second lower bicuspid. 



Plate 94 




PLATE 95. 
UXERUPTED PERMANENT TEETH— RIGHT SIDE OF HEAD. 

Boy, age 8 years. (Life size.) 

A. Frontal sinus. 

B. Orbit. 

C. Sphenoidal sinus. 

D. Ethmoidal cells. 
E and F. Antrum. 

G. Right central upper incisor. (Unerupted root only partly 

calcified.) 
H. Right permanent upper lateral incisor. 

/. Permanent upper cuspid. 

/. First upper temporary molar. 
K. Second upper bicuspid. 

L. Second temporary upper molar. (Partly absorbed, and 

crown destroyed by caries.) 
M. Second permanent upper molar. 
N. Second permanent lower molar. 

0. Crown of the second lower bicuspid in its crypt. 

P. Crown of the first lower bicuspid. 

Q. Teeth on left side of the jaw. 



Plate 95 




*r 



PLATE 96. 
SUPERNUMERARY TOOTH— LEFT SIDE OF HEAD. 

Boy, age 15 years. (Life size.) 

.4. Frontal sinus. 

B. Ethmoidal cells. 

C. Sphenoidal sinus. 

D. Roof of orbit. 

E. Antrum. 

F. Supernumerary tooth above upper lateral incisor, in palatal 

aspect. 

G. Third upper molar in its crypt. 
H. Third lower molar in its crypt. 



Plate 96 




PLATE 97. 
SUPERNUMERARY TOOTH— RIGHT SIDE OF HEAD. 

Girl, age 14 years. (Life size.) (Same subject as Plate 98.) 

A. Frontal sinus. 

B. Ethmoidal cells. 

C. Orbit. 

E. Antrum. 

F. Glenoid fossa. 

G. Condyle of inferior maxillary bone. 
H. Right upper cuspid. 

J. A supernumerary tooth showing the greater density caused 

by the overlapping of the right upper central incisor. 
J, Right upper lateral incisor. 



Plate 97 




PLATE 98. 
SUPERNUMERARY TOOTH— LEFT SIDE OF HEAD. 

Girl, age 14 years. (Life size.) (Same subject as Plate 97.) 

A. Frontal sinus. 

B. Ethmoidal cells. 

C. Orbit. 

D. Sphenoidal sinus. 

E. Antrum. 

F. Left upper cuspid. 

G. Supernumerary tooth. 

H. Left upper lateral incisor. 



Pi, ate 98 



r— s 









/ i 



■ ■>— * 



PLATE 99. 

VARIOUS ANOMALOUS CONDITIONS CONNECTED WITH THE 

TEETH. 

Fig. 1. Child, age 14 Years. 

A. Area where the missing second bicuspid should be. 
Fig. 2. Child, Age 14 Years. 

Opposite side of and corresponding part of jaw to that 
shown in Fig. 1. The first permanent molar appears to the 
right in this Fig. 
Fig. 3. Child, Age 13 Years. 

Absence of the second bicuspid. The temporary molar is 
present with no absorption of its root. 

Fig. 4.— 

B. Left upper permanent cuspid. 

C. Left upper permanent lateral incisor. 

D. Left upper supernumerary or temporary lateral 

incisor. 

E. Left upper temporary cuspid. 

F. Left upper permanent first bicuspid. 
Fig. 5.— 

Shows superior cuspids directly behind the central incisors. 
Fig. 6. Girl, Age 9 Years. 

G. Tip of the right upper permanent cuspid. 
H. Left upper permanent cuspid. 

I. Left upper temporary cuspid. 

J. Left upper first bicuspid. 

K. Left upper second bicuspid. 
Fig. 7. Child, Age 8 Years. 

Shows the absorption of the roots of the temporary cuspid 
and the first and second temporary molars. 
These teeth are about to be exfoliated. 

The permanent teeth are directly above and are in the 
process of eruption. 
Fig. 8. Girl, Between 8 and 9 Years of Age. 

L. Left upper permanent lateral incisor. 

M. Left upper temporary cuspid. 
Fig 9. Child, Age 10 Years. 

N. Right upper second bicuspid. 

0. Right upper temporary cuspid. 
Fig. 10. Girl, Between 7 and 8 Years of Age. 

P. Right upper permanent cuspid. 

Q. Right upper temporary cuspid. 
Fig. 11. Child, Age 10 Years. 

R. Right upper cuspid. 



FIG. I. 



FIG. 2. 



Plate 99 

FIG. 3. 





FIG. A. 



FIG. 5. 




FIG. 6. 




FIG. 7. 




FIG. 9. 



FIG, 8. 



FIG. IO. 







HP 



FIG. II 



r T 




PLATE 100. 
RHACHITIS OF SPINE. 

Colored boy, age 6 years. (Reduced 28J%.) 

The bones show a coarser structure, especially those of the 
vertebrae, than would be normal for a child of this age. 
The arrow points towards an area of rhachitis. 



Plate 100 








PLATE 101. 
OSTEOMYELITIS OF VERTEBRA. 

Girl, age 4h years. (Reduced 21%.) 

The arrow points towards the third lumbar vertebra, which 
is larger than the other vertebrae, and shows great disorganiza- 
tion in the lower part of the body and evidence of new formation 
of bone in the region of the transverse process. 



Plate 101 



. 







# 



w 






I 



d 



PLATE 102. 
TUBERCULOSIS OF THE SPINE, ILIUM, AND LEFT HIP. 

(Reduced 21*%.) 

A. Points toward the tubercular lesions of the third and 

fourth, lumbar vertebrae. 

B. Designates the same process in the ilium. 

C. Indicates an abscess of the left hip, the soft tissues being 

greatly involved. 



Plate 102 




PLATE 103. 
TUBERCULOSIS OF THE ILIUM. 

(Reduced 33|%.) 

The arrow points towards a tubercular condition of the 
iliosacral synchondrosis. 



Pirate 103 




v 



PLATE 104. 

TUBERCULAR ABSCESS OF THE SPINE. 

The arrows point towards the vertebras affected; namely, 
the ninth and tenth dorsal. 



PI.ATE 104 






PLATE 105. 
TUBERCULOSIS OF THE SPINE. 

Child, age 4 years. (Reduced 31%.) (Same subject as Plate 106.) 

10, 11 and 12 indicate the breaking down of the interver- 
tebral cartilages and the fusion of the bodies. 



Plate 105 




10 
11 

12 



PLATE 106. 

(Reduced 32%.) 

The same case as Plate 105 but presenting a lateral view 
of the spine. 

The arrow points toward an area of complete absorption 
of the bodies of the eleventh and twelfth vertebrae. 
B. The anterior aspect of the body. 



Plate 106 







Division VI 

THE BRONCHIAL NODES— BRONCHI— LUNGS— PLEURA— HEART- 
PERICARDIUM— ANEURISM 

Among the more difficult interpretations which we have to 
make in reading a Roentgenograph are those connected with intra- 
thoracic conditions. It is very necessary that we should first 
carefully study the normal conditions as seen in Plates 8 and 19, 
before attempting to interpret the abnormal. This is difficult since 
there is no one set of pictures which we can memorize as normal, 
and since the entire interpretation of an individual plate depends 
upon the comparison of the different densities which happen to ap- 
pear on that individual plate. These densities differ very much, 
whether of lung, heart, or liver. In a Roentgenograph of a normal 
thorax we can see the very slight density of the lung with its great 
radiability, the slightly greater densities of the bronchial nodes, the 
much greater densities of the heart and spine, and the still greater 
densities of the heart and spine where they overlap each other and 
show very slight radiability. To be noted carefully as an aid in 
detecting abnormal conditions are the outlines of the heart and its 
angle with the liver, especially on the right side. This angle is very 
important where there is a question between a pericardial effusion 
and an enlarged heart. To obtain the best results in Roentgeno- 
graphs of the thoracic organs certain details connected with the 
technic are important. Among these is the time of the exposure. 

Dr. Percy Brown has shown for me the great advantage of a 
short over a long exposure in Plates 107 and 108. Plate 107 shows 
an exposure of six seconds with the child breathing normally. 
Plate 108 shows the thorax of the same child taken with the 
respiration arrested and with an exposure of one second. The latter 

131 



13 2 THE ROENTGEN RAY IN PEDIATRICS. 

picture is seen to portray the lungs and heart with far greater 

accuracy than the former. 

The immobility of the parts taken explains these results, and 

naturally the immobility is greater the more the respiration is 

arrested. 

BRONCHIAL NODES 

The bronchial nodes under normal conditions are often not seen 
in the plate, but where the movement of the lung is at all restricted, 
as in disease, and often when the child is breathing very quietly 
and the expansion for half a minute is slight, the nodes when en- 
larged can be distinguished. They are seen especially to the right 
quite close to the border of the sternum, where they are not com- 
plicated by the picture of the heart. When enlarged they become 
quite distinct. 

Plate 109 shows the picture of a girl twelve years old. The 
lungs, pleura, pericardium and heart are normal. On the right side 
of the thorax just outside the boundaries of the heart and extending 
in a narrow area from the top to the bottom of the thorax are a 
number of separate dark areas in each of the interspaces. They 
evidently represent areas of enlarged bronchial nodes, and are seen 
at times in a normal thorax. 

Plate 110 shows a transposition of the heart and liver in a child. 
On the left side of the thorax there will be seen to be far less dark 
areas than on the right, but that whatever areas of lessened radia- 
bility there are on the left from the second to the seventh ribs are 
very marked. These dark areas show the characteristic appear- 
ances of an advanced tuberculosis of the bronchial nodes. The en- 
tire area to the left of the heart is mottled and heavy in outline, 
showing that the bronchial nodes are involved, but to a lesser 
degree than on the right side. The lower part of the lung on 
the left is seemingly normal; on the right side the density is very 



BRONCHI— LUNGS. 133 

great throughout, but is greatest from the fifth down to the tenth 
interspace. In this region and between the sixth and eighth 
interspaces just to the left of the spine can be seen the density 
of the heart. The cause of the general intensely increased density 
on the right is possibly thickened pleura, and except at the apex 
practically no lung substance can be seen. The dark area at the 
lower point of the thorax on the left is the picture of the transposed 
liver 

BRONCHI 

When expansion of the lung is restricted by consolidation, 
or when the breathing is unusually quiet, the bronchi can be dis- 
tinguished quite readily as faint areas of increased density radi- 
ating from the base of the lung. This is seen in Plate 19, Division 
I. If this appearance were produced by a mediastinal abscess the 
condition would be represented by a balloon-shaped area on either 
side of the mediastinal line instead of the radiating oranch-Uke 
irregularities seen in the picture. The movements of the bronchi 
are usually very free on account of their being surrounded by normal 
elastic tissue, and therefore we are more apt to see them when 
there is a consolidation of the lung, with its consequent restriction 
of motion. 

LUNGS 

Atelectasis. — There is no especial difference which can at present 
be detected between the decreased radiability of an atelectasis and 
that of a pulmonary consolidation. When at birth, in connection 
with symptoms of cyanosis, rapid irregular breathing, coldness of 
the extremities, and a subnormal temperature, we find parts of the 
lung-tissue showing a decidedly decreased radiability, we can with 
considerable assurance make the diagnosis of atelectasis. At a later 
period also as a sequel to pertussis an atelectasis may occur and be 
detected. When this condition is seen, the differential diagnosis 



134 THE ROENTGEN RAY IN PEDIATRICS. 

from the pictures resulting from infectious processes in the lungs is 
made by the absence of fever, and, if the child is old enough to ex- 
pectorate, by the absence of organisms in the sputa. In saying this 
we simply acknowledge our lack of skill in the interpretation, as a 
different picture is evidently before us, the atomic weight being 
different in the two conditions, and the radiability therefore being 
greater in atelectasis than in consolidation. When in the future 
the Roentgen apparatus has been perfected and the eye is more 
educated, we shall be able to accomplish far more than is now 
possible by means of our present art. 

Plate 134 represents the condition just described as collapse of 
the alveoli of the lung. 

The pictures which show abnormal conditions in the lungs vary 
according to the extent of the areas affected. Thus, when a whole 
lobe is involved, as in lobar pneumonia, a continuous broad tract 
of lessened radiability discloses such a condition, while smaller, 
irregularly distributed areas, usually bilateral, point towards a 
bronchopneumonia. Again, still smaller scattered areas over the 
whole lung lead us to suspect miliary tuberculosis. We must, 
however, merely consider these Roentgen pictures as suggestive 
rather than diagnostic, and only confirmatory of other signs, both 
rational and physical. In certain cases, especially in infants and 
in young children, where the physical signs from auscultation and 
percussion fail to detect a consolidation of the lung-tissue, the 
Roentgenograph shows a density which reveals the cause of the 
respiratory and constitutional symptoms corresponding to a con- 
solidation of the lung-tissue, and gives a means by which we can 
eliminate the presence of a foreign body or a mediastinal abscess. A 
mediastinal abscess is rare in early life except in connection with 
tuberculosis of the spine (Plate 104), where it can be detected by a 
picture in connection with the Roentgen examination of the spine. 



LUNGS. 135 

Plate 111 shows the homogeneous area of a lobar pneumonia 
of the left upper lobe in a girl three years old. This picture gives 
the characteristic appearance of an involvement of a whole lobe. 
The outline of the scapula can still be seen. The remainder of the 
lung and the density of the heart are normal. 

Plate 112 shows a lobar pneumonia in a boy twelve years old. 
The process is seen to involve the right middle lobe and is plainly 
seen in the third, fourth, fifth, sixth, and seventh interspaces. A 
consolidation on the left is also seen at the base of the lung from the 
fifth interspace down. The outline of the heart is rather indistinct, 
but the cardiohepatic angle can still be distinguished. The upper 
and lower lobes on the right and the upper lobe on the left seem to 
be normal. 

Plate 113 shows a lobar pneumonia of both lower lobes behind 
in a child ten years old. The right lower base shows much decreased 
radiability but the cardiohepatic angle is evident. The process 
seems to involve the entire lower lobe on the right. On the left a 
similar process in the lower lobe makes the outline of the heart rather 
indistinct. The upper lobes are practically normal, and on both sides 
show the faint pictures of the bronchi, especially at the right apex. 

Plate 114 shows the density of what from the clinical history 
was a case of unresolved pneumonia in a girl four years old. The 
pneumonic process is shown in the upper part of the right lung. 
There is a dorsal curvature from position shown in the plate. 

Plate 115 shows the thorax of a girl twenty-seven months 
old, where the clinical diagnosis of a Mongolian idiot was made. 
The history of this case has already been described in Division 
III, Plate 65, showing the hand and knee. When the child was 
first seen the clinical examination showed that it had a con- 
solidation of the upper part of the right lung. The Roentgeno- 
graph showed complete consolidation of the upper lobe. Four 



136 THE ROENTGEN RAY IN PEDIATRICS. 

weeks later another Roentgenograph was taken and showed, in the 
middle of the dark area representing the solidification, a round, 
clearly defined area with increased radiability. This is seen in 
Plate 116. The tuberculin test in this case was negative, and the 
question was whether we were dealing with a cavity or with an area 
of the decreasing consolidation of a resolution in a pneumonic area. 
The clinical signs were those of resolution. A Roentgenograph 
taken still later, Plate 117, showed that the light area was increasing. 

I was unable to get a later Roentgenograph of the case, but 
I was notified that the temperature was normal and that the 
child was improving. A series of Roentgenographs of a case of this 
kind would be exceedingly valuable for learning to determine whether 
we are dealing with a cavity or with an area of resolution. Sufficient 
work in this direction has not yet been done to justify us in any 
further conclusions regarding the case at this stage. Two months 
later the child was reported to have had a hemorrhage seemingly 
from the lung and to have died suddenly (no autopsy). 

Plate 118 shows the Roentgenograph of a child four years old. 
The coarse mottled appearance throughout both lungs shows gen- 
eral infiltration, and the definite areas of decreased radiability are 
what would be expected from a case of bilateral bronchopneumonia. 
To be noted is the still ununited upper epiphysis of the humerus, 
which is supposed to join at about five years. 

Plate 119 shows a pneumonia of the right lung produced by 
a china dolPs arm which was inspirated by a girl four years 
old. The progress of the case is seen in Plates 148, 149, and 150, 
Division VIII. 

Plate 120 shows the lesions of an acute miliary tuberculosis in 
the lungs of a child ten years old. 

Plate 121 shows the early signs of tuberculosis of the lungs 
which were not detected by the clinical examination until some time 



LUNGS— PLEURA. 137 

after the tuberculin test had shown the presence of tubercle bacilli. 
The Roentgenograph, on the other hand, at once showed that the 
case was one of miliary tuberculosis. 

Plate 122 shows the lesions in the right lung of a child twelve 
years old. There is an area of calcification about one inch in diam- 
eter. There are also multiple areas of calcified material, showing 
the remains of an old tubercular caseous area with an active process 
around it. 

Plate 123 shows the Roentgenograph of a girl three years old. 
This picture presents the lesions of emphysema, gangrene, and 
tuberculosis. The left lung shows the emphysematous condition 
expressed by extreme radiability, as compared with the picture of 
the right lung. At the base of the left lung a general infiltration 
has taken place and is represented in the plate by a mottled appear- 
ance due to a miliary tubercular lesion. The autopsy proved that the 
lung on the left side was completely disorganized and that the base 
was riddled with miliary tubercles. There was also a complete 
gangrenous condition of the left lung. The right lung was normal. 

Plate 124 shows acute miliary tuberculosis of both lungs in a 
girl twelve years old. 

Plate 125 shows a case of hydropneumo thorax in a boy seven 
years old, the picture being taken in the upright position. Plate 
126 shows the same boy taken when lying down. 

Plate 127 shows the condition of pneumothorax in the same 

boy, who one year previously had had an attack of hydro- 

pneumothorax. 

PLEURA 

Plate 128 shows thickened pleura over the left side of the chest 
in a boy six years old. The left side of the thorax will be seen to be 
of uniform density, except for a small area in the fifth interspace 
just beyond the border of the heart. Thoracentesis failed to detect 



138 THE ROENTGEN RAY IN PEDIATRICS. 

any fluid, and as the density did not change with change of position, 
the provisional diagnosis of a thickened pleura was made. The lung 
on the right side appeared to be emphysematous, the emphysema 
being partly caused by the forced compensatory action of the lung. 

It must be remembered that in all these Roentgenographs of the 
lungs the cases have been carefully examined clinically and that the 
interpretation of the plate must be much influenced by the clinical 
examination. In the pneumonic cases where they were at all ob- 
scure, not only was the exploratory needle used to support the 
diagnosis, but the tuberculin test was given in those cases where the 
resolution was prolonged; that is, the Roentgen examination was 
in all cases additional and confirmatory to other methods of exam- 
ination, and often proved to be the most valuable. 

Plate 129 shows an effusion into the left pleura of a child 
eight years old. There is a uniform radiability over the entire left 
lung, which was found to change as the position of the child was 
changed. It is to be noticed that where the fluid was greatest in 
amount, as in the middle of the involved area, the density was 
greatest, while on the edges it was less and showed greater radia- 
bility. The heart was slightly displaced to the right, and the right 
lung showed slight compensating emphysema. The bronchi are 
also seen on either side of the sternum. The diagnosis was con- 
firmed by an exploratory thoracentesis. 

Plate 130 shows a collapsed condition of the upper ribs on the 
right side in a girl six years old, resulting from an effusion, probably 
an empyema. The heart is drawn to the right and held there by 
adhesions. There is still either some fluid at the right base or a 
greatly thickened pleura. There is a compensatory emphysema of 
the left lung. 

Plate 131 shows an encapsulated empyema verified by an 
operation on the right side at the lower base in a boy ten years old. 



HEART— PERICARDIUM. 139 

HEART 

Plate 132 shows an extreme enlargement of the heart in a 
child ten years old, filling almost the entire anterior area of the 
thorax. The lung on the right side shows compression. The cardi- 
ohepatic angle is seen to be intact, and is extremely valuable in 
making the differential diagnosis from pericardial effusion, which in 
this case it closely simulated, since the encroachment of the dull 
area in the fifth right interspace was much greater than usual. 
This similarity of physical signs was accompanied by a similarity of 
rational signs, as the extreme dilatation and weakening of the heart 
prevented almost entirely the cardiac impulse from being felt and 
there was no audible murmur. There were orthopnoea, cyanosis, 
a weak fluttering pulse, and a picture as much of pericardial effu- 
sion as of enlarged heart, confirmatory paracentesis being con- 
sidered seriously, when the ray settled the question by showing 
clearly the cardiohepatic angle, and the consequent contraindica- 
tion for paracentesis. 

PERICARDIUM 

Plate 133, a child twelve years old, is an instance of what has 
just been stated in speaking of Plate 132. This picture shows a 
typical case of a heart enlarged considerably on both sides, but 
encroaching but little on the fifth right interspace, thus following 
the clinical rule as to the usual presence of resonance in that space 
in an enlarged heart. Around the heart is seen the greater radiability 
of the effusion, with its pyramidal outline below and at the sides 
and extending over the great vessels at the base of the heart, being 
indeed the typical outline of a pericardial effusion, namely a half 
circle with its greater radius to the left. 

So far as I know this is one of the first cases where a large peri- 
cardial effusion being present, and the rational symptoms of peri- 
cardial effusion and of enlarged heart being similar, it was possible 
not only to diagnosticate the effusion by the Roentgen method, 



140 THE ROENTGEN RAY IN PEDIATRICS. 

but to prove also that the heart was enlarged. This was accom- 
plished by recognizing the difference of radiability between the 
heart itself and the pericardial effusion. The Roentgen examina- 
tion was made in the upright position and the cardiohepatic angle 
as seen in the plate was obliterated. 

Plate 134 is a case of pericardial effusion in a child twelve 
years of age, where the outline of the heart shows it to be enlarged. 
The cardiohepatic angle is obliterated by the pericardial effusion. 
The lung shows compression of the pulmonary tissue, correspond- 
ing to what would be expected in the Roentgenographic picture 
produced by an atelectasis. 

Plate 135 is the picture of a pericardial effusion in a child. 
The decreased radiability extends from the sixth rib to the base on 
the right, and from the fourth interspace to the base on the left. 
The cardiohepatic angle was obliterated, as is seen on the right. 
The whole lung shows compression and lessened radiability. The 
darker area in the centre of the large and lighter area shows indis- 
tinctly the heart itself, which does not seem to be enlarged. The 
Roentgen ray gives us the only known method by which in most 
cases of large pericardial effusion a determination can be made as 
to whether the heart is of normal or abnormal size, suspended as 
it is in the pericardial sac. This is accomplished by a close obser- 
vation of the dark central outlines of the heart, which we are thus 
able to distinguish from the surrounding outline of the effusion and 
the still lighter area of the compressed lung. 

ANEURISM 

Plate 136 is the Roentgenograph of a boy twelve years old in 
whose thorax the clinical diagnosis of aneurism was made. The 
picture shows an area of increased density in the region of the great 
vessels at the base of the heart in the fourth left interspace, near the 
edge of the sternum, and its interpretation was confirmatory of the 
clinical diagnosis. The rest of the picture was normal. 



PLATE 107. 
NORMAL THORAX. 

Girl, age 7 years. (Same subject as Plate 108.) 
(Dr. Percy Brown.) 

Exposure 6 seconds. 

Child breathing normally. 

This picture was taken to show how a long exposure and 
the child respiring gives a decidedly blurred outline of the 
heart and an indefinite lung tissue in comparison with the 
results of a short exposure as shown in Plate 108. 



Plate 107 




PLATE 108. 
NORMAL THORAX. 

Girl, age 7 years. (Same subject as Plate 107.) 
(Dr. Percy Brown.) 

Exposure 1 second. 

Respiration arrested. 

Portrayal of the internal structures, especially the lungs, 
with increased accuracy, in comparison with the results shown 
in Plate 107. 



Plate 108 




PLATE 109. 
ENLARGED BRONCHIAL NODES. 

Girl, age 12 years. 

A slightly abnormal condition. 

The arrow points towards some enlarged nodes just to the 
right of the outline of the heart. 



Pl^ATE 109 




PLATE 110. 

TRANSPOSITION OF ORGANS.— TUBERCULOSIS OF THE LUNGS 
AND BRONCHIAL NODES. 

(Reduced 40%.) 

.4. The transposed heart. 

B. The liver transposed to the left. 

The left lung and the bronchial nodes show marked tuber- 
culosis. 



Plate 110 



LEFT 



RIGHT 




PLATE 111. 
PNEUMOCOCCUS LOBAR PNEUMONIA. 

Girl, age 3 years. (Reduced 33%.) 

The arrow points to a consolidation of the upper lobe of 
the left lung, at about the level of the angle of the scapula. 



Plate 111 




/ 







PLATE 112. 
DOUBLE PNEUMOCOCCUS LOBAR PNEUMONIA. 

Boy, age 12 years. (Reduced 42%.) 

A. Consolidation of the lower lobe on the left side. 

B. Consolidation of the middle and lower lobes on the right side. 



Plate 112 




PLATE 113. 
LOBAR PNEUMONIA. 

Child, age 10 years. (Reduced 42%.) 

A. Solidification of the right lower lobe with an area showing 

lessened consolidation just above it. Owing to the lack 
of movement in the lung, produced by its solidification, 
the bronchi of the upper lobes, especially on the right, 
have become quite distinct. 

B. Consolidation of the left lower lobe. 



Plate 113 




4 



j* 




r 



PLATE 114. 
UNRESOLVED LOBAR PNEUMONIA. 

Girl, age 4 years. (Reduced 31%.) 

The arrow points to a pneumonic process of the upper right 
lobe; there is also seen in this case a marked structural con- 
genital scoliosis to the right, involving the lower dorsal and 
upper lumbar vertebrae. 



PIRATE 114 




PLATE 115. 
LOBAR PNEUMONIA. 

Girl, age 27 months. (Reduced 28%.) (Same subject as Plates 65, 116, and 117.) 

Right upper lobe either unresolved or a beginning cavity. 



Plate 115 




PLATE 116. 

CONSOLIDATION OF THE RIGHT UPPER LOBE. MONGOLIAN 

IDIOT. 

Girl, age 27 months. (Same subject as shown in Plates 65, 115 and 117.) 

A. An area of lessened density has appeared in the middle of 
the solidification. Clinical signs of a cavity. 



P:late 116 



I 






PLATE 117. 

(Reduced 31%.) (Same subject as Plates 65, 115, and 116.) 

The area of density A shows marked increase of radia- 
bility. In the lower part of the lung the process, possibly 
tubercular, is seen in an area just above the diaphragm. On 
the left side the bronchial nodes are plainly seen owing to the 
lessened respiratory movements of the lung. 



Plate 117 








PLATE 118. 
BRONCHOPNEUMONIA. 

Child, age 4 years. (Reduced 42%.) 

Note alveolar infiltration over lower part of upper lobes 
on both sides. 



Plate 118 




PLATE 119. 

PNEUMONIA OF THE RIGHT LUNG FOLLOWING THE INHALATION 
OF A CHINA DOLL'S ARM. 

Girl, age 4 years. (Reduced 39%.) (Same subject as Plates 148, 149, and 150.) 

Arrow points towards a pneumonic area in the right upper 
lobe produced by the arm. 



Plate 119 




PLATE 120. 
ACUTE MILIARY TUBERCULOSIS OF THE LUNGS. 

Boy, age 10 years. (Reduced 49i%.) 

General fine infiltration over the upper lobes of the lungs. 
A. Artifact. 



Plate 120 









PLATE 121. 
EARLY MILIARY TUBERCULOSIS OF THE LUNGS. 

Age 3 years. 

Scattered areas, especially marked over the middle third 
of the right lung. 



Pirate 121 




PLATE 122. 
PROBABLE OLD TUBERCULAR PROCESS OF THE RIGHT LUNG. 

Child, age 12 years. (Reduced 43|%.) 

A. Area of calcification. 

B. Probably an active process surrounding A. 



Plate 122 






■m- 







■ 



T*/n. 1 x2» • MM m ^Vx . 4 £jk; 



PLATE 123. 

EMPHYSEMA, GANGRENE, AND TUBERCULOSIS OF LEFT LUNG. 
(VERIFIED BY AUTOPSY.) 

Girl, age 3 years. (Reduced 25|%.) 

A. Area of emphysema. 

B. General infiltration of miliary tuberculosis. Right lung 

normal. 



Plate 123 







B 



PLATE 124. 
ACUTE MILIARY TUBERCULOSIS OF BOTH LUNGS. 

Girl, age 12 years. 

The arrows point towards the tubercular processes. 



Pi, ate 124 




PLATE 125. 
HYDROPNEUMOTHORAX. 

Boy, age 7 years. (Same subject as Plates 126 and 127. "Pediatrics," fifth edition, 

Plate XIII.) 

The picture is taken with, the boy in an upright position. 
The level of the effusion on the left side is clearly shown, as 
is the marked displacement of the heart to the right. 



Plate 125 




PLATE 126. 
HYDROPNEUMOTHORAX. 

Boy, age 7 years. (Same subject as Plates 125 and 127. "Pediatrics," fifth edition, 

Plate XIV.) 

The picture is taken with the boy lying down. 

The effusion is now seen to occupy nearly all the left chest 
with the exception of the extreme apex of the lung. 

The cardiac area of density shows the heart to be displaced 
to the right. 



Plate 126 




PLATE 127. 
PNEUMOTHORAX. 

Boy, age 8 years. (Same subject as Plates 125 and 126, taken one year later.) 

Heart displaced to right. 

The arrow points to a greatly increased radiability in the 
left lung. 



Plate 127 




PLATE 128. 
THICKENED PLEURA. 

Boy, age 6 years. 



Arrow points towards the dark area which indicates the 
pathologic process. 



Plate 128 




PLATE 129. 
PLEURISY WITH EFFUSION. 

Child, age 8 years. (Reduced 40%.) 

The arrow points towards the effusion which fills the whole 
left side of the chest, with possible slight displacement of the 
heart to the right. 



Plate 129 




P 





PLATE 130. 
COLLAPSE OF RIBS ON RIGHT SIDE OF THORAX. 

Girl, age 6 years. (Reduced 39%.) 

This condition followed an old empyema on the right side, 
with resulting adhesions. 

Heart displaced to right and held there by adhesions. 
Compensatory emphysema in left lung. 
The arrow points to the collapsed ribs. 



Plate 130 





X 









PLATE 131. 
ENCAPSULATED EMPYEMA. 

Boy", age 10 years. (Reduced 45%.) 

The arrow points towards an encapsulated empyema at 
the base of the right lung. 

This case was operated upon and the Roentgen diagnosis 
was found to be correct. 



Plate 131 




PLATE 132. 
DILATED HEART. 

Boy, age 10 years. (Reduced 48%.) 

The arrow points towards a distinct cardiohepatic angle. 



Plate 132 





PLATE 133. 
PERICARDIAL EFFUSION. 

Child, age 12 years. (Reduced 45%.) 

A and B. The outlines of the heart. 

C. The outline of the distended pericardium on the right. 
It is to be noted that the cardiohepatic angle is obliterated 



Pjlate 133 




PLATE 134. 
ENLARGED HEART WITH PERICARDIAL EFFUSION. 

Child, age 12 years. (Reduced 45%.) 

A. The dilated heart. 

B. The outline between the dilated heart and the effusion on 

the left. 

C. Collapsed lung tissue, representing very well the appearance 

which would be found in atelectasis. 



Pilate 134 




PLATE 135. 

PERICARDIAL EFFUSION AND OBLITERATION OF THE CARDIO- 
HEPATIC ANGLE. 

(Reduced 45*%.) 

The arrow points towards a probable effusion in the right 
pleura. 



Plate 135 



' jfl 'V.: 












miMi0 














mt, I ' )'j&SG&Il!.^ V ' *j& K^bHwEj^- n ■ ^ *• •V» H '• -i'"^ ;''x'2i»' 











PLATE 136. 
ANEURISM. 

Boy, age 12 years. (Reduced 50%.) 

The arrow points towards an increased area of density 
just above the base of the heart, on the left side of the ster- 
num, and presents the clinical signs of aneurism. 



Plate 136 




Division VII 

THE ABDOMEN 

Although it is difficult to obtain satisfactory Roentgenographs 
of the abdominal organs, yet great advances have been made by 
using new methods. A striking illustration of this is shown in Plates 
137 and 138. 

These Roentgenographs were taken by Dr. Percy Brown to 
show the greater accuracy of outline obtained by a short exposure, 
Plate 137, seven seconds, the child not breathing, over Plate 138, 
a longer one, thirteen seconds, taken during normal respiration. The 
child had been given a large dose of bismuth and in this way the 
resulting great density was obtained. The plates illustrate how 
the comparatively clean-cut edge of the stomach shown in the short 
exposure is contrasted with the blurred outline of the long exposure. 
There are a number of congenital malformations of the intestine, 
represented by obliteration of the intestine from various causes, such 
as fibrous bands, yet it is rare that we can show these conditions by 
Roentgenographs. The malformations of the oesophagus and stomach 
are also difficult to obtain a picture of, but considerable progress is 
being made every day in the diagnosis of gastric conditions. 

Plate 139 represents the stomach of an infant five weeks old, 
showing the so-called hour-glass contraction. The outline of the 
stomach is very distinct, especially on the left side where it is of the 
normal size, whereas on the right side it is very small, due to a con- 
traction just behind the lumbar vertebra. This gives the hour- 
glass appearance. Otherwise the stomach appears to be normal. 
The outline of the intestine is distinctly marked below that of the 
stomach. 

Plate 140 shows the stomach of the same subject after the 

hi 



142 THE ROENTGEN RAY IN PEDIATRICS. 

hour-glass contraction has been removed by the inflation of the 
stomach with air through a soft rubber catheter. 

We must remember that as our technic is perfected and our 
powers of interpretation increased we shall probably in the future 
understand much which we cannot now interpret, although we 
know it must be on the plate. Especially in abdominal cases we are 
probably looking at conditions which are undoubtedly in the plate 
but which we cannot recognize. 

Plate 141 shows the picture produced by a fluid in the abdo- 
men of a girl twelve years old. The picture in the middle is darker 
than at the sides, which, according to George, is on account of the 
greater depth of the fluid in the middle. Dr. George also interpreted 
the dark areas above the diaphragm as being partially produced by a 
considerable amount of oedema which was present in this case and 
also by compression of the lung. 

Plate 142 shows what appears to be a mass of enlarged mesen- 
teric nodes in the right side of the abdominal cavity in a child ten 
or eleven years old. By clinical examination it was impossible to 
detect hardened faeces or any tumor or foreign body. As the child 
did not react to the tuberculin test, the diagnosis as to whether the 
enlarged glands were of tubercular origin was left in abeyance. 



PLATE 137. 
NORMAL ABDOMEN. 

Boy, age 9 years. (Same subject as Plate 138.) 
(Dr. Percy Brown.) 

Exposure of stomach for 7 seconds, with respiration (dia- 
phragm) arrested, resulting in a more accurate portrayal of 
the gastric outline. 

Stomach contains about one ounce of bismuth. 

Note sharp outline of stomach and the greater clearness of 
detail in comparison with the same subject under long exposure 
shown in Plate 138. 



Plate 137 




PLATE 138. 
NORMAL ABDOMEN. 

Boy, age 9 years. (Same subject as Plate 137.) 
(Dr. Percy Brown.) 

Stomach contains about one ounce of bismuth. 

Long exposure of the stomach for 13 seconds during normal 
respiration. 

Note the blurred outline of the stomach in comparison 
with the sharply defined outline and general picture of the 
same child under short exposure, 7 seconds, shown in Plate 137. 



Plate 138 




PLATE 139. 
HOUR-GLASS CONTRACTION OF STOMACH. 

Infant, age 5 weeks. (Reduced 20%.) (Same subject as Plate 140.) 

A. Distended cardiac end of stomach. 

B. Small area of the pyloric end of the stomach partially 

separated from cardiac end by contraction. 



Plate 139 







PLATE 140. 
HOUR-GLASS CONTRACTION OF STOMACH. 

Age 5 weeks. (Reduced 165%. ) (Same subject as Plate 139.) 

Stomach distended with air by means of a soft rubber 
catheter. 

A. The cardiac end of the stomach dilated to twice the 

size which appeared when it was only dilated by 
the contraction. The contraction has disap- 
peared, and the area represented by C still shows 
a slight contraction. 

B. Stomach-tube lying along the greater curvature of 

the stomach. 
D. The distended intestine. 



Plate 140 




PLATE 141. 
ABDOMINAL ASCITES. 

Girl, age 12 years. (Reduced 46%.) 

The broad area of increased density in the middle of the 
abdominal area represents the fluid, and is marked by A. On 
either side of this central dark area are areas of less density 
which represent a thinner layer of fluid, B. 



Plate 141 




PLATE 142. 
CALCIFIED MESENTERIC NODES. 

(Reduced 35%.) 

The arrow points to an area of increased density just to 
the right of the fourth lumbar vertebra. Clinical differentiation 
indicated that this mass represented an area of calcification. 



Plate 142 







/ 


_^ — 








i 




^r 








I 















Division VIII 

FOREIGN BODIES 

The importance of the Roentgen method of examination for the 
detection of foreign bodies has now been recognized for some time, 
and its value is increasing every day as our knowledge of its scope 
and the perfection of its technic increases. Even in the abdomen, 
which usually presents such difficulties for obtaining a satisfactory 
plate, great progress has been made in the line of diagnosis, and in 
the near future we shall probably receive much aid from the ray in 
differentiating a tubercular mass from a foreign body. Children 
are so much more apt than adults to swallow or inhale foreign bodies 
of all kinds, that the role which the Roentgen ray plays in this 
class of cases has become an important one. 

Plate 143 shows a stone in the urethra of a girl thirteen years 
old. In this case a cystitis had existed for ten years, and although 
the child had never been considered very strong she was bright and 
active. Even as early as her third year she had complained of 
painful micturition, and the pain in the bladder was at times intense. 
At no time had the relief from the s} r mptoms been complete, relapses 
being frequent. The Roentgenograph, besides showing an oval 
stone approximately the size of a moderate-sized hen's egg, also dis- 
closed in the centre of the stone a bent pin with a distinct head 
to it. The stone was removed by operation. 

Plate 144 is that of a boy five years old. It was known thai the 
child had swallowed a nail, and the Roentgenograph shows dis- 
tinctly the presence of the nail in the intestine. 

Plate 145 shows a penny which was by means of the ray de- 
tected in the oesophagus. The location of the penny having been 
definitely made by the ray, it was easily removed with the (esopha- 
geal forceps. 

143 



144 THE ROENTGEN RAY IN PEDIATRICS. 

Although the lodgement of a foreign body in the larynx and 
trachea is comparatively rare, it occurs more frequently in children 
than in adults. The symptoms which indicate a foreign body are 
those of respiratory obstruction. It is very important that the 
foreign body should be located precisely, and this is best accom- 
plished by obtaining a Roentgenograph. Instrumental localization 
of any kind, on account of the danger of producing a sudden inspir- 
ation, is often contraindicated. The picture tells us whether instru- 
mental removal should be attempted or tracheotomy be performed 
at once. 

Plate 146 shows the definite localization made by the ray of a 
hook in the larynx of a child four years old. It had been noticed 
for two days that the child was unable to cry aloud and had 
difficulty in breathing. The hook was located opposite the fifth 
intervertebral cartilage and was extracted through the mouth. 

The differential diagnosis to be made by the ray in cases of 
this kind is from acute tracheal laryngitis, trauma, and membra- 
nous laryngitis. All these, however, may be diagnosticated by other 
special symptoms directed to the larynx as the source of the irri- 
tation. The inferior quality of this electro-engraving is due to the 
difficulty of technic in these cases. 

Plate 147 shows a nail which was detected in the lung after it 
had been there for five years, in a boy twelve years old. The nail is 
seen in the right lower lobe. It had been inspirated five years before 
the picture was taken, and was not suspected at that time, although 
a Roentgenograph had been taken. The boy had been treated 
during this interval of five years for various diseases of the lungs 
and pleura. The Roentgenograph shows the nail surrounded by a 
dark area indicating thickened pleura and collapsed lung. In the 
picture will be noticed a dark round area in the ninth interspace at 
about the posterior axillary line. This represents a piece of lead 



FOREIGN BODIES. 1-15 

shot placed there as a guide at the time of the first operation, after 
which this picture was taken. The tenth rib just below and in a line 
with the shot will be seen to have been resected for about an inch. 
It will be noted in this picture that there is practically no lung- 
tissue in the right lower chest. An operation was not successful, 
although performed twice. 

Plate 148, the same case as Plate 119, Division VI, shows 
the presence of a doll's china arm which was inhaled into the 
lung. The history of this case is of considerable interest. A 
girl four years old entered the hospital February 10, 1907, with 
pulmonary symptoms. The statement was made that she had 
swallowed the arm of a china doll in October, 1905. At that time 
she became cyanotic and had a severe attack of coughing. Since 
that time she had had considerable dyspnoea, had never seemed well, 
had coughed spasmodically from time to time, but had been up and 
about with a good appetite, sleeping well, and with no history of 
any other symptoms. On entering the hospital, she did not look 
very well and her temperature was 102^° F., respirations 62, and 
pulse 165. She had a short irritating cough and there was a marked 
dilatation of the alae nasi. There were signs of consolidation in the 
lower right back and the respiratory excursions were greater on the 
left side. In the left back there were lessened vocal resonance and 
tactile fremitus, and at about the middle there was hyper-resonance 
over an area of 5 cm. in diameter. The rest of the physical exami- 
nation was negative. There was a leukocytosis of 55. 500. The 
Roentgenograph showed a pneumonic process corresponding to the 
clinical examination of the righl lung. Nothing was shown by the 
ray in the left lung. The pneumonic condition showed well in the 
plate but is not so satisfactory in the electro-engraving. 

Plate 149, taken February loth, shows the presence of the for- 
eign body (the picture is reduced 35 per cent, and the plate was taken 

10 



146 THE ROENTGEN RAY IN PEDIATRICS. 

with the child's face lying on the plate). The foreign body was 
as seen in the Roentgenograph 1J cm. long and J cm. in diameter, 
situated at the junction of the seventh rib with the left edge of the 
sternum. This corresponded to the piece of the arm which had been 
broken off from the child's doll. The diagnosis was made of the in- 
halation of a piece of a china arm, occluding probably one of the left 
bronchi, and followed by pneumonia of the right lung, with prob- 
able interference of expansion of the left lung, as an aspiration 
of the left chest was negative. 

Plate 150, taken February 10th, shows the same picture. The 
child's symptoms increased in severity, but the white count dropped 
to 23,000 on February 12th and to 18,300 on February 13th. The 
sputum was purulent and showed numerous micrococci. No tubercle 
bacilli, influenza bacilli, or pneumococci were present. On February 
20th there were a few pneumococci. February 25th the white 
count was 16,400 and the physical signs in the lungs were the same. 

A plate taken February 13th showed that the position of the 
arm had changed, it now being seen between the sixth and 
seventh ribs. 

A plate taken February 14th showed the position of the arm 
to be about the same, but this picture was taken with the child 
lying on its face on the plate. The temperature at this time was 
ranging from 99 J° to 101° F., with the pulse 140 and the respirations 
150 to 160. 

The child coughed up the china arm on March 12th. A Roent- 
genograph was immediately taken, and it was found that the pic- 
ture of the arm had disappeared, but that the pneumonic process 
still continued. The white count was 14,700. 

On March 2d the left lung was practically normal and there 
were signs of resolution in the right lung. 

On March 16th the cough, dyspnoea, and general symptoms had 



FOREIGN BODIES. 147 

almost disappeared and the child was up and about and was looking 
well. The temperature, pulse, and respirations were practically 
normal by March 21st and the signs in both lungs were normal. The 
child was discharged well March 28th. 

Although the bronchoscope had been used successfully in a 
number of cases, it was not deemed advisable after a few attempts 
to use it further in this case, as the Roentgenograph showed that 
the arm was located too deeply in the chest. 

Plate 151 shows a penny localized by means of the Roentgen 
ray in the left inguinal region. The penny is seen in the descending 
colon, as a large round area just above the crest of the ilium. The 
outline of the intestine on the right is clearly seen. 

Plate 86, Division III, shows a needle which was by chance 
detected in the right hip when the child was being examined for 
some other trouble. 

The following group of plates shows needles in various parts 
of the body : 

Plate 152 shows a needle in the knee-joint. 

Plate 153 shows a needle in the knee (same case). 

Plate 154 shows a needle in the dorsum of the foot. 

Plate 155 shows a needle among the tarsal bones and in close 

juxtaposition to the cuneiform bone. 
Plate 156 shows a needle in an area just under the little toe. 



PLATE 143. 
STONE IN URETHRA, ENCAPSULATING A PIN. 

Girl, age 13 years. (Actual size.) 

Fig. 1. Roentgenograph of Stone Intact after Removal. 

Fig. 2. Stone in Urethra. 

Fig. 3. Photograph of Stone Broken up after Removal. 



FIG. 1. 



Plate 143 




FIG. 2. 




PLATE 144. 
FOREIGN BODY IN INTESTINE. 

Boy, age 5 years. (Reduced 37%.) 

A. The leader points towards an increased area of density 
caused by a nail, swallowed by a boy 5 years old. The 
peristaltic action of the intestine has rendered the outline 
of the nail indefinite. 



Plate 144 




PLATE 145. 
FOREIGN BODY IN (ESOPHAGUS. 

(Reduced 35%.) 

The arrow points towards a round, even area of great den- 
sity, caused by an old Canadian penny. 



PliATE 145 




—ii ■ 



PLATE 146. 
HOOK IN THE LARYNX. 

Child, age 4 years. (Actual size.) 



Plate 146 




. 



i 



PLATE 147. 

NAIL IN RIGHT LUNG. 

The arrow points towards a distinct area of increased den- 
sity, having the shape of a nail, and at about the junction of 
the ninth rib with the spine. Just to the right, and a little above 
in the sixth interspace, is a small round area showing great 
density; this represents the shot used as a guide. 



Plate 147 




PLATE 148. 
DOLL'S CHINA ARM IN LUNG. 

Girl, age 4 years. (Reduced 35%.) (Same subject as Plates 119, 149, and 150.) 

The arrow points to a small area of increased density at 
about the junction of the seventh rib with the sternum, on the 
left side. 



Plate 148 








PLATE 149. 

(Reduced 41%.) (Same subject as Plates 119, 148, and 150, but taken face down on 

the plate.) 

The area of density indicated by the arrow is seen to be a 
little higher and about the junction of the sixth rib with the 
left edge of the sternum. 



RIGHT 



Plate 149 

LEFT 



PLATE 150. 

(Life size.) (Same subject as Plates 119, 148, and 149.) 

Shows the same condition a little more clearly. 
The arrow points to the china arm. 



Plate 150 




PLATE 151. 
PENNY IN THE DESCENDING COLON. 

(Reduced 38%.) 

A. A round area of marked density, just above the crest of 

the ilium (penny). 

B. A round area of much lessened radiability corresponding 

to the coils of one of the intestines. 



PliATE 151 




■■■ 




PLATE 152. 
NEEDLE IN THE KNEE-JOINT. 

(Same subject as Plate 153.) 

The arrow points to the needle. 



Plate 152 




PLATE 153. 
NEEDLE IN THE KNEE-JOINT. 

(A front view of same subject as Plate 152.) 

This picture shows a different position of the leg, thus 
giving the exact location of the needle. 




Plate 153 

I5T I ■ 



PLATE 154. 
NEEDLE IN FOOT. 

(Same subject as Plate 155.) 

The arrow points to the needle. 



Pi, ate 154 




\ 




'/ 



PLATE 155. 
NEEDLE IN FOOT. 

(Actual size.) (Same subject as Plate 154.) 

This picture shows a different view of the foot, and thus 
locates the needle exactly. 

The arrow points to the needle. 



Pirate 155 




* 









k 




PLATE 156. 

NEEDLE IN THE TISSUES AROUND THE PHALANX OF THE 
LITTLE TOE. 

(Reduced 35%.) 

The arrow points to the needle. 



Pi. ate 156 




Division IX 

THE EXTREMITIES 

In describing the diseases of the extremities which can be de- 
tected by the Roentgen ray, we are dealing with at least one-half of 
the information about diseased conditions which can be obtained 
from Roentgenographs. In this varied class of cases it is especially 
necessary to use the utmost care in the differential analyses, the 
rules for which I have already given in the Introduction. It is also 
apparent that this is the class of cases where it is absolutely neces- 
sary thoroughly to study and master at least the gross anatomy of 
the part investigated. This is all the more difficult and important, 
as the anatomic conditions change so rapidly in early life that it 
is not a question of the normal completed anatomy of the adult, 
represented by one single set of anatomic pictures, which we have 
to interpret. On the contrary, it is the numerous sets of frequently 
changing normal pictures which it is necessary for us to recognize 
as normal in order to determine what is abnormal. Of especial 
significance in this connection are the difficulties which arise in 
young subjects in distinguishing after an injury whether an epiphysis 
has been separated by trauma in a case where it should be united 
normally in accordance with the special stage of development of the 
individual. Often this can only be accomplished by the aid of the 
Roentgen ray. It is well in this class of cases to train the eye to 
recognize any differences from what we have learned to consider 
normal in our previous study of living anatomic conditions at 
different periods of development as described in Divisions I and II. 

IRREGULAR DEVELOPMENT 

Hand. — As an example of retarded development is the hand of 
a child eight years old shown in Plate 157. To determine whether 

149 



150 THE ROENTGEN RAY IN PEDIATRICS. 

or not this is a normal hand, we should first turn to the Roentgeno- 
graphs of the normal hands, which have been described in Divi- 
sion II as indices of the various stages of development. From 
a comparison with these we should then select the group which 
corresponds to the hand of this child eight years old. On doing 
this we find that Group C, which represents children from two to 
three years old, approaches nearer to this picture than to any of the 
others; while the group which would correspond to the normal 
development of a child eight years old would be Group J. We see 
at once, however, that this hand showing delayed development is 
also anomalous in its type, even if the child were only two or three 
years old. An anomaly is especially noticeable in the very small 
epiphysis of the radius, which corresponds more in size to what 
would usually be found in Group H, that is, in children about six 
years old. The carpal bones, only three in number, as we have 
already stated, would place this hand naturally in Group C. On 
examining, however, Group C, which is marked by the os magnum, 
unciform and cuneiform bones, we see that the epiphyses of the 
metacarpal bones are present, and those of the phalanges also, 
while this hand shows a total absence of all the epiphyses of both 
metacarpal bones and phalanges. So far, however, as the bones 
themselves are concerned they simply show a slight deficiency in 
the lime salts. 

Wrist. — In like manner if we compare, as is shown in Plate 
158, the anomalous radius of a child thirteen years old with that 
of the normal hand of thirteen years, as shown in Plate 40, Group 
M, some decided differences will be detected. This occurs in the 
carpal bones, which are quite as well developed or even more so 
than in Group M. They also show quite as great, if not greater 
development of the epiphyses of the metacarpal bones and of the 
proximal ends of the first phalanges. We also notice the early 



THE EXTREMITIES. 151 

ossification of the epiphysis of the radius. On examining closely 
we see that this epiphysis of the radius is already almost com- 
pletely ossified. The epiphysis of the ulna, on the contrary, has not 
yet completed its growth and will be seen to show a decidedly de- 
layed development in comparison with that of the normal ulna, 
Plate 40, Group M, where it has practically united with the epiphy- 
sis. On the other hand, this epiphysis of the ulna corresponds very 
much more to that seen in Group L, a child about twelve years old. 
It is very evident that the growth of this ulna is not yet completed, 
and its development will not be completed until its epiphysis has 
become completely ossified. The radius, on the other hand, having 
practically completed its growth as regards length, will always be 
shorter than normal in comparison with the ulna. This early ossi- 
fication of the radius probably depended upon an injury to the 
bone, which stopped the epiphyseal growth sooner than was normal, 
while the uninjured ulna continued to grow. It is interesting in 
this case to notice the sesamoid bone in the neighborhood of the 
metacarpal bone of the thumb and its counterpart in the normal 
hand, Plate 40, Group M. 

Foot. — Plate 159 shows the scaphoid of the left foot of a boy 
six years old. For two or three weeks it had been noticed that this 
boy limped on walking and favored the left foot. The Roentgen 
examination showed a very much undeveloped scaphoid, which was 
not sufficiently supporting the arch of the foot, as the normal sca- 
phoid of the same period of development should do. This boy had a 
twin brother in whom the Roentgen ray showed the same unde- 
veloped condition of the scaphoid, but to whom this abnormality 
did not cause any trouble. After a properly adjusted shoe was 
applied to the foot, and exercises to strengthen the muscles were 
carried out, the difficulty was obviated and the lameness passed 
away. 



152 THE ROENTGEN RAY IN PEDIATRICS. 

Femur and Tibia. — Plate 160 shows the early ossification of the 
femur and tibia in a boy. Both these bones remained shorter than 
they should have been if their normal growth had continued. This 
is shown in the complete ossification of their epiphyses. On the other 
hand, the fibula is still growing, as its epiphysis is unossified. There 
is no involvement of the soft parts. The tendon of the quadriceps 
is distinctly shown. On the lower and outer surface of the femur 
there is seen to be a slight thickening of the periosteum. 

Having learned to interpret these cases of delayed and early 
ossification we can next study such conditions as are abnormal 
from various causes and which show a change of normal outline. 
This class is represented by such conditions as swelling of the 
soft tissues, whether in the muscles or in the periosteum, and by 
exostoses of the bones. The recognition of these changes of normal 
outline and density is often of great value in that it clearly and 
surely shows whether the bones are affected, and indicates to the 
surgeon exactly what his operative procedure should be. 

ABSCESS 

Plate 161 shows the increased density and local increase of 
outline in the soft tissues around the left humerus in a boy nine 
years old. A subcutaneous injection had been given at this point, 
and there was so much tenderness, swelling, heat and redness that a 
Roentgenograph was taken to see if the bone was affected. As 
shown by the picture no disturbance of the bone was found, and the 
outline of the cortex was seen to be smooth, even, and normal. An 
operation disclosed an abscess of the soft tissues. 

Plate 162 shows a swelling of the soft parts over the heel in a 
boy twelve years old. It will be seen that the density is increased, 
the radiability being lessened on account of a hematoma just below 
the os calcis. The epiphysis of the os calcis shows an increase in 
size beyond the normal epiphysis at this age, this being due to the 



THE EXTREMITIES. 153 

increased amount of blood which the bone has received into its 
tissues. The other bones of the foot and ankle are normal. 

SARCOMA 

Myelogenous sarcomata are rare in children, but may occur in 
or about the larger of the long bones. They usually attack the 
shaft of the bone and produce changes similar to certain grades of 
osteomyelitis, differing only in that the latter presents an outline 
showing periosteal reaction. In medullary sarcomata certain areas 
of increased density appear which resemble spiculse or islands of 
osseous material and show actual absorption of the bone, with none 
of the normal portions of the bone remaining about this point. 
Of the cases seen at the Children's Hospital, a marked increase of 
tissue has been apparent. In osteomyelitis we generally have a 
more definite proliferation of the periosteum, and a more definite 
formation of new bone about the necrosed area, or pieces of bone 
which have not been absorbed. 

Thigh. — Plate 163 shows a boy four and a half years old with 
sarcoma of the left thigh. 

Fig. 1 shows a Roentgenograph where a lateral view of the 
femur is seen with the tumor definitely encapsulated among the 
muscles of the thigh. The bone is shown to be perfectly normal 
and the joint is not involved in any way. The mass of the tumor 
can easily be seen through the surrounding muscles by the decreased 
radiability. 

The photograph, Fig. 2, shows a swelling of the posterior region 
of the left thigh, with a bulging both on the inside and outside of 
the thigh extending down into the popliteal space. 

The diagnosis of sarcoma by the ray was proved to be correct 
by operation. 

Plate 164 shows a medullary sarcoma in the lower part of the 
femur of a child about twelve years old. 



154 THE ROENTGEN RAY IN PEDIATRICS. 

Plate 165 shows a periosteal sarcoma in the lower part of the 
femur of a boy ten years old. 

ATROPHY 

Hand and Arm. — Plate 166 shows an outline of the bones of the 
hand, radius, and ulna, which is seen to be abnormal in comparison 
with the normal bones. This picture was taken from a boy thirteen 
years old, and shows the outlines of extreme atrophy. Between the 
middle of the shafts of both bones there is a somewhat suspicious 
appearance suggesting the beginning of a periostitis. The cause of 
the condition in this child was unknown, although syphilis was 
suspected on account of the periosteal thickening of both radius 
and ulna. There is an increased radiability of both radius and ulna, 
and also in parts of the bones of the hand. This hand and lower 
arm should be compared with the normal hand of about the same 
age shown in Plate 40, Group M, where it will be noticed how much 
larger are the bones and how much greater is the density. 

POLIOMYELITIS 

Hand. — Plate 167 shows an atrophy in quality with its increased 
radiability, and also an atrophy in size of the hand of an infant one 
and a half years old in its sixth week of an attack of poliomyelitis 
anterior. On comparing the bones of the right hand with those of 
the normal left hand the atrophy of quality is especially marked and 
is seen in all the bones, radius, ulna, epiphysis of the radius, os mag- 
num, unciform, the metacarpal bones and the phalanges, with their 
respective epiphyses. 

Shoulders. — Plate 168 represents the shoulders and upper arms 
of an infant twelve months old. The left shoulder and humerus 
show the results of an attack of acute poliomyelitis of six weeks' 
duration. The humerus, especially at its neck, is seen to show 
increased radiability as compared with the other side. This is also 
well shown in the epiphysis. The increase in the radiability extends 



THE EXTREMITIES. 155 

the whole length of the bone. There is a slight evidence of decrease 
in the radiability of the scapula and of the acromial process. The 
thorax and chest are those of a perfectly normal child. 

Elbow and Wrist. — Plate 169 shows the elbow, lower arm, and 
wrist of a child four years old, with marked atrophy of the muscles 
and bone following an attack of poliomyelitis anterior. To be 
especially noted is the atrophy in size and also in quality of the 
carpal bones and of the radius and ulna. The atrophic condition of 
the muscle is not especially well shown in the reproduction, but in 
the original plate was well marked. 

SUBPERIOSTEAL HEMORRHAGE 

Thigh. — Plate 170 shows the change from the normal outline 
caused by an injury to the thigh followed by a subperiosteal hemor- 
rhage. The periosteum is seen to be stripped from almost the entire 
length of the femur, and the resulting clot to have become organ- 
ized. The plate represents a side view of the thigh. 

EXOSTOSES 

Exostoses of the bones and allied conditions are comparatively 
rare in children, though occasional cases are seen in which an exam- 
ination by the Roentgen ray demonstrates that in all the epiphyses 
or near the epiphyses of the body rough irregularities or formations 
of new bone appear with distortion of the bone at these points. 
Occasionally only a single exostosis is seen. This condition usually 
occurs in children in or about the epiphyses. The exostoses show a 
definite bone structure generally, but they may take a more or less 
fantastic shape. The normal bone about the exostoses does not 
change in any way. The cause of these exostoses, whether the 
condition is multiple or single, is somewhat obscure. Infection and 
traumatism represent in part the cause of the single exostoses. 
They may arise from a number of infections, such as scarlet fever. 



156 THE ROENTGEN RAY IN PEDIATRICS. 

Astragalus. — Plate 171 shows an exostosis of the astragalus in 
a child twelve years old. The outgrowth is shown on the anterior 
surface of the bone and appeared as a sequela of scarlet fever. 

Tibia and Fibula. — Plate 172 shows the lesions of a case of 
multiple exostoses in a child five years old. The change in the nor- 
mal outline of the bones of the fibula and tibia will at once be recog- 
nized. Especially to be noted is the exostosis at the inner side of 
the upper diaphysis in comparison with the clear-cut line of the 
lower diaphysis of the right tibia. In this case practically all the 
bones of the body had similar exostoses. 

Knee. — Plate 173 shows a well-marked case of multiple exos- 
toses in the neighborhood of the knee-joint in a boy five years old. 
There is a very evident new formation of bone at the lower end of 
the femur. The upper end of the fibula shows an irregular and dis- 
torted appearance with a complete absence of its epiphysis. The 
inner and upper edge of the tibia also shows an exostosis. In this 
case there is seen to be a considerable change in the quality of the 
bones, as well as the change in shape. 

Femur. — Plate 174 shows an exostosis of the lower end of the 
femur. 

Plate 175 shows an exostosis of the upper part of the right 
tibia in a boy twelve years old. This picture also shows a number 
of narrow transverse lines passing across the whole front of the 
diaphysis. These are supposed to be the remains of old ossified 
epiphyseal lines. 

CALLUS 

Plate 176 shows the feet of a girl ten years old. A year previous 
to being seen a set of steel plates had been prescribed for her by a 
physician, supposedly for the breaking down of the arch of her foot. 
She had worn the plates continuously and showed on the inner sur- 
face of each foot in the region of the scaphoids a hard thickened 



THE EXTREMITIES. 157 

callus. The Roentgenograph was taken in order to discover whether 
there were any malformations or exostoses of the bones of the feet. 
The lesions evidently came from wearing badly fitting plates, and 
an examination with the Roentgen ray showed that the arch was 
not broken down, Plate 177, but on the contrary was higher than 
usual. It also showed the outer surface of the scaphoid on the left 
foot to be somewhat irregular, a little roughened and with lessened 
radiability. In comparison with the right foot, which is normal, it 
is seen how much smaller is the border line of the left tarsus, and 
the arch of the foot is rather higher than normal. The plates were 
removed and the thick callus formation gradually disappeared. 

FLAT-FOOT 

Plate 178 shows the condition of moderate flat-foot in compari- 
son with the high instep just shown in Plate 177. 

TRAUMATISM 

Traumatism in children plays an important part, in that sec- 
ondary changes due to injuries to the different tissues and bones of 
the skeleton may occur, which disturb, either by actual destruction 
of bone or by injury to the epiphyses, the growth and the future 
usefulness of a given bone or joint. 

The lesions of the extremities which are most readily detected 
by the ray are those which are produced by traumatism. The most 
exact knowledge of the epiphyseal lines and of the epiphyses, as to 
their normal development at different periods of growth and when 
they become united to their diaphyses, is a prerequisite for the 
correct interpretation of the many disturbances which result from a 
traumatism of these parts in early life. In J. S. Stone's admirable 
monograph on acute epiphyseal and periosteal infections in infants 
and children, he states that among infants and children many le- 
sions of the bones and joints are seen which differ materially from 
those which occur in adults. The character of all lesions involving 



158 THE ROENTGEN RAY IN PEDIATRICS. 

the bones of infants and children depends largely on the anatomy 
of the epiphyses and to a less extent on that of the periosteum. 
This is true whether the cause is traumatic or infectious. The 
epiphyseal lines are a very frequent seat of infection, are a source 
of mechanical weakness, and are the seat of numerous lesions. 
The strong periosteum is a source of mechanical strength, but influ- 
ences the spread of infectious processes. Epiphyseal separations 
are generally regarded as very similar to fractures. In infants and in 
young children there must be innumerable injuries to the epiphyses 
which pass unrecognized, since the lesions cannot be demonstrated 
clinically. In relatively severe injuries to the epiphyses localized 
tenderness, and perhaps some swelling with disturbance of func- 
tion, are the only signs which can be detected. An intimate 
knowledge of the epiphyseal lines, therefore, and of the gradual 
appearance and ossification of the epiphyses is especially necessary. 
Of much interest also are the degrees of separation and the final per- 
manent attachment of the condyles and of the tuberosities, abnormal 
conditions of which, such as separations and displacements, are of 
interest to both physician and surgeon. This is true not only from 
their relation to treatment, but from a medicolegal point of view, 
and from their liability to provide a nidus for the dissemination of 
infectious processes. 

Since the Roentgen ray has come into use so extensively the 
study by it of injuries to the osseous system has been of great 
assistance and value to the surgeon. Fractures heretofore unrecog- 
nized or seldom recognized can now be easily detected, indeed 
fractures of all kinds have been diagnosticated much more com- 
monly since the Roentgen method has been used systematically. 

The technic in the Roentgen examination of cases of trauma- 
tism or suspected fractures of any of the bones is important in 
certain details. 



THE EXTREMITIES. 159 

First, that the part to be examined, as for instance the wrist- 
joint, should be carefully immobilized and the tube centred directly 
over the part suspected. 

Second, two views, one at right angles to the other, should be 
taken, that is, an anteroposterior view and a lateral. In all cases 
of fractures of the bones in which these two views are accessible, 
such as the long bones, and with the exception of the shoulder and 
hip-joint, this examination should be made as a matter of routine. 

Third, it is better to have the cases examined without dressings, 
such as splints or plaster. If this is contraindicated for any reason, 
it must be borne in mind that there will be an increase in the general 
size of the part under examination. Aside from this, however, there 
will be no actual distortion, so that the relations of the part will be 
the same one to another. 

I shall present a few illustrations of the various forms of trau- 
matism, such as separation of the epiphyses, dislocations, and 
fractures. These injuries are so common and so varied that I 
shall speak only of a few representative traumata, a thorough 
study of which will aid very much in the diagnosis of other 
injuries of the same parts. 

Knee. — Plate 179 represents an injury to the knee-joint in a 
child twelve years old. The Roentgenograph shows that the inner 
condyle of the femur has been displaced backwards. The epiphys- 
eal cartilage is rough and irregular along its posterior two-thirds. 
There is a slight tissue-reaction in the knee-joint as shown by hazi- 
ness. The shafts of the femur, tibia, and fibula are perfectly normal. 

Epiphysis and Shaft of Humerus. — Plate 180 shows a complete 
dislocation of the epiphysis and a marked displacement of the shaft 
of the humerus. It also shows a complete fracture of the head of 
the humerus. 

Fracture of Humerus. — Plate 181 shows a fracture of the shaft 



160 THE ROENTGEN RAY IN PEDIATRICS. 

of the humerus in a boy eleven years old which gave the clinical 
picture of a dislocation rather than a fracture. There is, however, a 
complete transverse fracture at the anatomical neck of the humerus. 

Fracture of Surgical Neck of Humerus. — Plate 182 shows a slight 
amount of displacement of the shaft of the humerus of a boy twelve 
years old. There is also a fracture of the surgical neck of the 
humerus. 

In regard to the locality of various injuries it may be stated 
that fractures of the ribs in children are rather rare, as the ribs are 
very pliable and stand a comparatively greater strain than they do 
in adults. 

Fractures of the bones that make up the shoulder in children, 
with the exception of the clavicle, are comparatively rare, and here, 
again, the importance of considering the normal anatomy of the 
shoulder- joint at different ages becomes important. 

Fracture of Humerus. — Plate 183 shows a fracture of the hu- 
merus in a child four years old. This picture was taken through the 
dressings and shows a break in the continuity of the outer border of 
the humerus in the region of the surgical neck with a slight impac- 
tion of the shaft. Otherwise the bones are normal. 

Knee-joint: Dislocation and Fracture. — Plate 184 represents a 
dislocation of the epiphysis of the femur and a fracture of the con- 
dyle in a boy five years old, and shows a lateral view of the knee- 
joint. The picture shows a complete transverse fracture and back- 
ward dislocation of the condyle with new formation of bone at the 
lower end of the femur which unites with the dislocated epiphysis. 
No changes in the shafts of the bones are present. 

Tibia: Green-stick Fracture. — Plate 185 shows the result of an 
untreated green-stick fracture at the lower third of the tibia. The 
tibia in this region seems to be irregular in outline, and there is an 
increase on its concave side. This consists of an increase of the 



THE EXTREMITIES. 161 

periosteum and of the cortical substance of the bone. There is a 
slight increase in radiability at the lower end of the tibia with 
slightly decreased radiability in the same region of the fibula. The 
epiphyseal lines, however, are normal. 

Femur: Intracapsular Fracture. — Plate 186 shows an intracap- 
sular fracture of the femur in a boy ten years old. The whole joint 
is rather hazy, but along the acetabulum is seen the separated 
epiphysis of the femur. The femur itself shows some increased 
radiability. 

Knee-joint; Femur: Dislocation of Epiphysis and Condyle. — 
Plate 187 shows the knee-joint of a boy ten years old, with the 
epiphysis and the inner condyle dislocated from the lower end of 
the femur. Otherwise the structure of the bones is practically 
normal. 

Humerus: Fracture. — Plate 188 represents a fracture of the 
lower end of the humerus in a child ten years old. The picture 
shows a transverse fracture of the lower end of the shaft of the 
humerus with displacement of the lower fragments inwards. In 
this case the condition was considered clinically a perfect reduction. 

Radius: Green-stick Fracture. — Plate 189 shows a green-stick 
fracture of the radius occurring in a child twelve years old. As 
shown by the grayish-white, faint transverse line in the lower third 
of the radius, there is a break, but the periosteum has not broken 
through, the break being in the cortical and medullary portion of 
the bone. The irregular areas in the plate show parts of the band- 
age, and we should remember, as I have explained before, that 
although the details of the parts are not altered on this account 
the whole picture is somewhat larger than it otherwise would be. 

Radius and Ulna: Impacted Fracture. — Plate 190 shows a com- 
plete transverse fracture with slight impaction of both radius and 
ulna in a boy between three and four years old. At the top of the 

n 



162 THE ROENTGEN RAY IN PEDIATRICS. 

picture are to be noted the proximal ends of the first phalanges, 
and also the fingers of the hand of the assistant who was holding the 
child's fingers down. Also to be noted is the development of the 
lower epiphysis of the radius, which corresponds to the anatomical 
Group D, from three to four years. 

Radius and Ulna: Fracture. — Plate 191 shows a complete frac- 
ture of the radius and ulna in a child three years old. The Roent- 
genograph is taken through the splint after the fracture had been 
reduced. The capitellum, as it appears in the elbow- joint close to 
the lower end of the humerus, is normal at this age. 

Tibia: Fracture. — Plate 192 shows the otherwise normal foot of 
a child twelve months old, with a small incomplete fracture just 
above the lower epiphyseal line of the tibia on the anterior surface. 
The rupture of the tendo Achillis is well marked. The fracture 
occurred at the time the child was being treated for the correction 
of club-foot. 

Astragalus: Fracture. — Plate 193 shows a fracture of the astraga- 
lus in a boy eleven years old. The bones of the foot are normal with 
the exception of the astragalus, which shows a complete fracture 
in its upper third. This fracture was due to catching the foot in a 
revolving wheel. 

Tibia and Fibula: Fracture and Abscess. — Plate 194 shows an 
abnormal condition at the lower end of the tibia and fibula with a 
bridge uniting the two, which seems to represent the osseous con- 
nection of an old fracture. The lower end of the tibia and the bones 
of the foot are seen to be very finely pencilled, indicating a marked 
lime absorption. Posterior to the epiphysis of the fibula there is 
seen to be a definite swelling of the soft parts due to the forma- 
tion of an abscess. The whole foot illustrates a tubercular process 
with the formation of an abscess but without actual destruction 
of the bone. 



THE EXTREMITIES. 163 

Os Calcis: Fracture of Epiphysis. — Plate 195 shows a fracture of 
the epiphysis of the os calcis in a child ten years old. Clinically 
this child had marked pain and tenderness over the region of the 
heel. In making a differential diagnosis of this lesion we must 
remember that the epiphysis of the os calcis sometimes unites by 
two centres and gives this same appearance at this age. Mobiliza- 
tion of the heel in this case gave relief, and the supposition there- 
fore was that it was a fracture. Cases of this kind enunciate very 
strongly the importance of avoiding the overlooking of slight frac- 
tures by calling to our aid an examination by the Roentgen ray. 
Especially is this important in children, who often can be relieved 
of their pain and general discomfort at once as soon as the seat of 
the lesion has been located, while unless we do ascertain this by 
means of the ray the lesion not only might not recover rapidly, but 
might even be increased in its severity with a possible final result of 
impaired usefulness of the part. 

Tibia: Fracture. — Plate 196 shows a condition arising from an 
ununited fracture of the tibia in the left leg of a girl twelve years 
old. The fracture is in the middle and upper third of the tibia and 
shows an attempt to unite. The whole tibia shows marked atrophy, 
not only in thickness but also in length and quality, as shown by 
the greatly increased radiability of the shaft. The fibula, however, 
shows a compensatory increase in size and decrease in radiability. 
It has practically taken up the function of the tibia. The right leg 
is normal in every respect for this age, and the injured leg should be 
carefully compared with it. 

JOINTS 

There has been a great deal of discussion concerning the proper 
classification of conditions in which the joints are affected. In our 
efforts to decide upon a rational and correct nomenclature, much 
opposition has arisen from the fact that physicians are loath to 



164 THE ROENTGEN RAY IN PEDIATRICS. 

change the names by which they have been accustomed to recog- 
nize, or rather think that they recognize, certain groups of clinical 
symptoms. One of the reasons for this is that they do not appreciate 
that the same clinical symptoms may be produced by a number of 
different etiologic factors, and that again these factors in their origin 
may simply arise from traumatism without specific infection, or 
again may arise from a large number of different specific infections. 
So long, therefore, as a classification on a clinical and symptomatic 
basis is retained, no advance can be made in the proper and intelli- 
gent understanding of the different diseases. On the other hand, 
there are those who prefer a pathologic classification. Here, again, 
the mistake is made in thinking that precise and exact pathologic 
conditions always correspond to a specific etiology. In quite a large 
number of pathologic conditions which are found at the autopsy 
there is no doubt that the lesions do not necessarily arise from one 
specific cause. On the contrary they are merely terminal lesions 
which may represent a number of different primary conditions 
of a special disease. When we consider that in most cases we have 
had to wait until the patient has died in order to discover what the 
lesions were which corresponded to his special symptoms, it is no 
wonder that such confusion has arisen from our having to depend 
upon dead pathology. It is very evident also that now that we are 
enabled to study living pathology by means of the Roentgen method 
a great advance can be made in classification. We can often recog- 
nize the early lesions of a special disease, and taking advantage 
of this we can eventually sweep away the false position and result- 
ing obscure ideas which we have arrived at from our study of 
the lesions represented by dead pathology. The truth of what I 
have just said is manifest when we come to consider disturbances of 
the joints, whether from simple congestion, trauma, without infec- 
tion or followed by infection, or infection without trauma by direct 



THE EXTREMITIES. 165 

infection of the part through the blood. In approaching this subject 
we would naturally begin with those affections of the joints which 
might be considered non-infectious, and to be the result of trau- 
matism. In quite a number of cases where I have been unable to 
determine in a lesion of the joint that the resulting pathologic con- 
dition has arisen from an infection, and therefore is a so-called 
idiopathic disturbance of the joint, I have had to assume for the 
time being that I was dealing with an injury without infection.. Cer- 
tain acute conditions of a joint, especially of the knee, will, following 
an acute injury, present the symptoms of heat, swelling, tenderness, 
effusion into the joint, with absorption and complete recovery. This 
sequence of symptoms has so frequently been met with that it per- 
haps seems hard to believe that infection has taken place in any 
way etiologically. It is very probable, however, that in the future 
the number of cases which will be proved to be non-infectious will 
grow less and less as our knowledge of infectious processes increases, 
and when our power of detecting specific organisms is more perfected. 
A specific organism may have a brief clinical history. It may be so 
benign that its effect simply represents an acute disease running a 
very rapid course and tending to recover. We must for the present, 
therefore, allow that the whole subject is sub judice. I would, how- 
ever, enunciate the general principle that the only safe course to 
take in any injury of the joint, whether from mild, or moderate, or 
severe trauma, is that it should be at once treated as though possibly 
an infection had taken place or might take place very shortly. Only 
in this way can we avoid the mistakes which we see made over and 
over again, when a slight trauma is passed over without much 
notice. 

I shall not attempt to make any classification of this set of 
cases, as it is hardly within the scope of the work in which I am 
now engaged. I merely wish to show the living pathology of the 



166 THE ROENTGEN RAY IN PEDIATRICS. 

joints with the same idea in view as when we study the dead pathol- 
ogy. For instance, I shall show what an inflamed congested joint 
looks like in a Roentgenograph: the appearances which are met 
with in the different disturbances of the diaphysis: the epiphyseal 
line: the epiphyses : the capsular lining of the joint: the appearance 
when an effusion is present; the appearance when resulting adhe- 
sions have taken place, or still further that villous formation which 
is the result of a number of pathologic conditions of the joints. Hav- 
ing learned to recognize the different lesions which may occur in 
acute and chronic processes, we are in a position to discuss the lesions 
which result from various disturbances of the joints. 

Following out this idea I shall now refer to some plates which 
represent a few of the lesions which are met early and late in disturb- 
ances of the knee-joint, whether traumatic or infectious. 

Knee: Congestion. — Plate 197 illustrates the results of a con- 
gestion of the knee of a boy six years old. There is seen to be an 
hypertrophy in the size of the epiphyses of both femur and tibia in 
the left knee in comparison with the right. There is also increased 
radiability in the epiphyses on the left. In addition to this there is 
some thickening of the soft parts and capsule around the knee- 
joint. The epiphyseal line of the femur and tibia is comparatively 
normal. The epiphysis of the fibula to the left has appeared, whereas 
it is absent on the right. This increase in size of the epiphyses of 
the left knee over that in the right, and the presence of the epiphy- 
sis of the fibula on the left, are due to the increased blood supply 
occurring in the process of a chronic infection. This picture also 
shows lines radiating transversely across the lower diaphysis of the 
femur and less marked in the upper diaphysis of the tibia. These 
narrow lines are supposed to represent the old lines of the epiphyses. 

Knee; Epiphyseal Line: Epiphysitis and Osteochondritis. — Plate 
198 illustrates an inflammation of the epiphyseal line in the knee 



THE EXTREMITIES. 167 

of a child one year old. The soft parts in this case are normal, with 
the exception perhaps of a slight amount of thickening around the 
knee-joint. The structure of the femur is practically normal until 
the epiphyseal line is reached. It is to be noticed that the epiphys- 
eal line is darker than normal, showing new formation of bone. The 
epiphyses of the tibia and fibula also show the same characteristic 
increased deposit of lime, which points strongly to inflammatory 
proliferation around the epiphyseal line. All the epiphyses in this 
case also show the same change in the epiphyseal lines. The con- 
dition is mostly one of epiphysitis, but there may also be a certain 
amount of osteochondritis. 

Knee; Tibia: Old Trauma, Suppuration of Epiphysis. — Plate 
199 illustrates the condition of a tibia due to an early trauma fol- 
lowed by suppuration of the epiphysis of the tibia. This occurred 
in a girl ten years old. The femur in this case is normal and its 
epiphyseal line is still easily seen and shows no evidence of ossifi- 
cation. Along the epiphyseal line of the tibia, however, there is 
complete ossification of its epiphysis. The fibula is seen to be longer 
than the tibia, which we would expect, as its epiphysis is still unossi- 
fied and it has continued to grow, while the tibia has ceased to grow. 

Knee: Old Inflammation — Infectious Arthritis, Atrophic Variety. — 
Plate 200 illustrates one of the results of inflammation of the knee- 
joint in a child three years old. There is marked thickening of the 
soft parts around the knee-joint and a slight roughening of the 
femoral epiphysis. The shafts of the bones are normal, except that 
there is a rather fine pencilling at the lower end of the femur and 
at the upper end of the tibia. The plate illustrates the condition 
of infectious arthritis of the atrophic variety. 

Knee: Inflammation — Villous Arthritis. — Plate 201 shows one 
of the end results following inflammatory disturbance of the knee- 
joint. This is the class of cases which is spoken of as villous arthritis, 



168 THE ROENTGEN RAY IN PEDIATRICS. 

and may arise from a number of causes, or rather follow a number of 
processes. Roentgenographs of cases of this kind have been rather 
confusing, owing to the attempt of certain writers to have this con- 
dition represent a class rather than the result of a number of inflam- 
matory conditions. The tissues around the knee-joint are seen to 
be thickened, especially in the popliteal space. The capsule of the 
joint is greatly thickened and can be easily outlined. The joint itself 
is full of a roughened villous hypertrophic growth. This lesion was 
supposed to be the result of an acute septic infection of the knee, 
accompanied by swelling, heat, and pain, but the symptoms did not 
subside under the usual treatment. Before operating the Roent- 
genograph showed a simple villous arthritis and at the operation no 
infection was discovered. 

Knee: Inflammation, Ankylosis. — Plate 202 represents the end 
results of a severe case of inflammatory disturbance of the knee- 
joint not recognized in the early stages and resulting in ankylosis 
of the joint in a boy thirteen years old. The picture shows complete 
ossification between the heads of the femur and tibia. To be no- 
ticed is the great change in the structure of the bone at the lower 
end of the femur and at the upper end of the tibia, and that a for- 
mation of new bone extends directly across the line of ossification. 
The patella is seen to be greatly atrophied in quality rather than in 
size, a natural result arising from disuse, as the joint was perfectly 
stiff and could not be bent. 

Before speaking more in detail of the infectious class of cases in 
connection with the joints, in other words, infectious arthritis, a few 
explanatory suggestions may be of use to the student. Of especial 
significance are the results of Stone's investigations of these cases 
in early life, since he has had for many years unusual opportunities 
for examining and operating on infants and young children at the 
Infants' Hospital. 



THE EXTREMITIES. 169 

He draws attention to the anatomical fact that there is a very 
free vascular supply of the epiphyseal lines by terminal arteries and 
that this increases the liability of infections reaching these points 
through the blood. This, in addition to the supposition that infec- 
tions entering through the ear, tonsil, and other sources attack 
most readily those parts where there is an unusual blood supply, 
and where there are tissues especially susceptible to infection, 
makes it highly probable that most infections of the joints in early 
life begin in the epiphyseal lines. The underlying cause of these 
infections may often be traced directly to some preceding disease 
which not only impairs the general health but also aids to bring the 
infecting organisms into the circulation. Thus in young children it 
is common to see epiphyseal lesions after pneumonia, measles, or 
scarlet fever. In very young infants the unhealed umbilicus seems 
to be a not infrequent source of infection. The opportunity for 
infection through the tonsils and lymphoid tissue of the nasopharynx 
is generally recognized. In this way a preceding disease which allows 
the entrance of the organism into the circulation leads to an infec- 
tion of a vascular area, the resistance of which has been impaired 
by perhaps only a slight trauma. Since the pathologic process of 
this area may extend still further and may result in an exudate, it is 
well to study certain points in connection with the anatomy of the 
joints. In order to understand rightly the picture of an exudate 
in the neighborhood of a joint, it is also important and even neces- 
sary to bear in mind the anatomic relation of the epiphysis to the 
capsule of the joint. When the epiphyseal line reaches within the 
joint-capsule an exudation of pus can reach the joint whenever the 
epiphysis is separated by suppuration. In the wrist the capsule is 
inserted into the epiphysis of the radius and ulna, and not into the 
sac, so that pus to reach the joint has to perforate the cartilaginous 
epiphysis. In the hip-joint and in the shoulder-joint the epiphyseal 



170 THE ROENTGEN RAY IN PEDIATRICS. 

line reaches within the joint-capsule, and thus when the epiphysis 
is separated by suppuration the pus can enter the joint. The same 
reasoning is true of the upper epiphysis of the tibia, for the capsular 
ligament of the knee does not cross the epiphysis but is inserted into 
it, therefore when separation occurs the pus burrows under the 
periosteum but does not break into the knee. Different parts around 
the knee-joint may be involved according to where the pus has the 
freest vent. Sometimes the extension may be into the extra-articu- 
lar tissues, or up into the shaft of the femur, or again down into 
the joint itself. 

The point of especial interest in regard to this group of cases is 
the exact point of the original focus of infection. At operation it is 
rarely possible to determine the location of the original focus accu- 
rately. It seems probable that it is usually either the epiphyseal line 
close to the periosteum, or the periosteum near to the epiphyseal 
line. The reasons for this belief are: 

This location seems usually to be the centre of the abscess. 

The condition is brought on by the same factors which bring on 
true epiphysitis, namely, slight trauma combined with the 
presence of an infecting organism. 

The early symptoms are identical with those of acute epiphysitis. 

These abscesses occur most frequently at the age at which epiphys- 
eal injuries are most common. 

The location of these abscesses, their course, their symptoms, and 
their whole clinical history differ absolutely from those of 
abscesses originating in lymph-nodes and also from those 
originating among the muscles and fascice. 

On the other hand Stone has never found one of these extra- 
articular abscesses showing any erosion of the bones, though very 
frequently the periosteum is slightly frayed and ragged close to the 



THE EXTREMITIES. 171 

epiphyseal line, as though it might have been perforated at this 
point. It is, therefore, probable that in all these varieties of cases 
there is an infection beginning in or close to the epiphyseal line, and 
that when suppuration occurs the pus spreads along the anatomic 
lines of least resistance. These depend on : 

The spot in the epiphyseal line at which infection occurs, which 

is determined presumably by the nature of the trauma. 
The anatomy of the epiphysis. 

If the original focus of infection is at the periphery of the epi- 
physeal line the pus is very likely to find a vent into the surrounding 
tissues before any extensive damage is done to the epiphyseal line 
itself. On the other hand, if the infection occurs at the centre of 
the epiphyseal line the chance of a complete separation and conse- 
quent necrosis of the whole epiphysis is much greater. Thus the 
entire question is one of anatomy. 

The cases of dissecting periostitis usually occur in somewhat 
older children than do the cases with abscesses in or about the 
joints. While some apparently start at the epiphyseal line, in other 
cases the infection seems to be primary under the periosteum. Peri- 
osteal infections occur usually in the tibia, radius, or ulna. They 
are especially common about the ankle and wrist, and somewhat 
less common about the lower end of the femur. It seems reasonable 
to suppose under these circumstances that direct injury of exposed 
parts plays a most important role in the causation of these lesions. 

In another class of cases connected with the periosteum and its 
separation from the bone we may have two results which should be 
carefully looked for in our Roentgen examination. For instance, 
the bone may become necrotic, not as a result of inflammation 
from infection of the marrow, but as a result of the interference 
with nutrition incident to the stripping off of the periosteum and 



172 THE ROENTGEN RAY IN PEDIATRICS. 

the consequent destruction of the nutrient vessels. In this case 
there would be necrosis but not osteomyelitis. 

Stone gives the following varieties of lesions originating in the 
epiphyseal line : 

Acute epiphysitis resulting in the sequestration of the epiphysis 
and incidental involvement of the joint. 

Acute epiphysitis with perforation into the joint, resulting in an 
acute articular abscess. 

Acute epiphysitis with perforation outside the joint into the extra- 
articular tissues (an extra-articular juxta-epiphyseal abscess). 

Acute epiphysitis with extension beneath the periosteum (a dis- 
secting periostitis) . 

In addition to this a dissecting periostitis is found occasionally 
away from the epiphyseal line and without evident lesion in the 
bone even on careful search. 

With this rather formidable array of the different etiological 
factors which may produce an arthritis, we should certainly appre- 
ciate how important it is that aid in our differential diagnosis by 
the Roentgen ray should be obtained early. During infancy the 
wide area of cartilage and the vulnerability of the epiphyseal line 
give ample opportunity for suppuration to spread outward rather 
than to enter the shaft. As development advances, as the cartilage 
at the epiphyseal line becomes thinner, and as the epiphyseal line 
itself becomes less well defined, the likelihood of sepsis spreading 
into the medullary cavity increases. Thus the infections involving 
no other part of the bone than the epiphyseal line are particularly 
to be expected in the youngest patients and cannot possibly occur in 
adults. True osteomyelitis is more common in older children, and 
any infection beginning in the epiphyseal line in adults must of 
necessity be a true osteomyelitis. 



THE EXTREMITIES. 173 

In older children dissecting periostitis is relatively common. 
The pain, and especially the tenderness and swelling in such cases, is 
usually more widely diffused than in an acute osteomyelitis. 

The value and the limitation of Roentgenographs in these cases 
should be clearly understood. In those taken early in the course of 
acute infections beginning in the epiphyseal line in infants and 
young children there is no reason to expect any change from the 
normal. In such cases the disease involves the cartilage, which 
shows at best but vaguely even in the clearest Roentgenographs. 
The most that can be looked for is an irregularity of the end of the 
diaphysis, or a broadening or haziness between the epiphysis and 
diaphysis. Neither of these points can be determined accurately or 
even approximately without wide experience. Early in the course 
of infections under the periosteum the Roentgenograph will show no 
change in the bone, unless it is a slight degree of roughening of the 
outer part of the cortex. In due time the new forming periosteal 
bone may be seen separated very slightly from the underlying cor- 
tex. The negative value of a good Roentgenograph, however, as 
showing the absence of any advanced lesion within the diaphysis, is 
often of the utmost importance and should never be disregarded. 

In connection with what will be said concerning congenital 
syphilis it is well to remember that this may often during infancy 
cause well-defined swelling and tenderness at the epiphyseal lines. 
Among older children, of course, periosteal syphilitic lesions are 
very common, and indeed it has long been noted that syphilitic 
periostitis is the marked lesion in older children, while syphilitic 
osteochondritis most commonly occurs in young infants. As a rule, 
however, especially if the Roentgen ray is used, there is not much 
probability of the syphilitic lesions being confused with the acute 
epiphyseal or periosteal infections. 

In like manner we should bear in mind that the subperiosteal 



174 THE ROENTGEN RAY IN PEDIATRICS. 

hemorrhages, so commonly occurring in infantile scorbutus, at times 
with their extreme pain and tenderness simulate closely pus in the 
same locality, but in this case the general clinical symptoms would 
aid in the differential diagnosis. The symptoms of scorbutus show 
a slow onset and a relatively low temperature, in contrast with the 
acute attacks of subperiosteal effusion from other causes. 

I believe that in all these cases Roentgenographs should be 
taken from time to time through the course of the disease, even 
when the symptoms are mild. The profession will gradually learn 
that the physical examination of these cases gives us infinitely less 
information than does the Roentgen. This method of examination 
is more valuable than any other, whether it be in cases of severe 
infantile scorbutus, or of osteomyelitis, infectious periostitis, infec- 
tious epiphysitis, or infectious osteochondritis. 

In regard to the special organisms which give rise to infectious 
arthritis and to osteomyelitis, we may say that in the chronic cases 
of low grade we find mostly the staphylococcus, while in rapidly 
septic cases the streptococcus is most common. The pneumo- 
coccus produces a comparatively chronic, while the bacillus of 
typhoid either an acute or chronic condition. We must remember 
also that the conditions in these infections, as seen in children up 
to the age of puberty, are not altogether like those of the adult, and 
that the characteristic pictures seen in adults often cannot be shown 
in children. It should be noted for the purpose of differential diag- 
nosis that clinically the characteristic picture of an acute poly- 
arthritis may be present, and yet it may be very difficult to deter- 
mine the cause of the condition. The reason for this is that we at 
times see in the living individual terminal results of an acute, sub- 
acute, or chronic inflammatory process which may be slightly active 
or entirely quiescent. 

It is also well to note that we can have a combination of both 



THE EXTREMITIES. 175 

atrophy in quality and atrophy in size in certain cases which show 
simply a decrease in the size of the bone with an absorption of the 
lime salts. This is seen especially in the chronic forms of arthritis 
as well as in tuberculosis of the bone or in general tuberculosis. It 
is also seen in paralytic conditions, such as poliomyelitis anterior, 
as already shown in Plate 168; also in some of the malignant osteo- 
mata, where spontaneous fracture takes place, and very rapidly 
extends in both directions, but usually towards the origin of the 
nutrient arteries. Here we find also a diminution in the size of the 
bone and an actual absorption of the substance of the bone with- 
out any tendency towards the formation of a callus. 

In connection with those cases in which there is an infection of 
the periosteum, we should note that in acute infections by a pyo- 
genic organism outside the joint-capsule the process may start with 
a direct infection of the periosteum or through a roughened or 
ragged periosteal line. In the former case we may have the appear- 
ance in the Roentgenograph of a definite beginning of proliferation 
of the periosteum. 

EPIPHYSITIS 

Certain anatomic facts are worthy of note when we are con- 
sidering inflammatory conditions of the epiphyses. There is a very 
marked difference between the epiphyses as they exist in the joint 
of a child and in an adult. It is very important that by means of 
the Roentgenograph we should not mistake a normal separation of 
the epiphysis in a young subject for a fracture, since the same pic- 
ture in an adult would almost invariably represent the latter. It 
is also known that where a dislocation is produced by trauma in 
an adult, it is much more likely in the case of a child to cause sepa- 
ration of the epiphysis. It is all the more important to recognize 
these injuries of the epiphyses in young subjects since, unless prop- 
erly treated, they are followed by suppuration and stiffness in a 



176 THE ROENTGEN RAY IN PEDIATRICS. 

neighboring joint, resulting perhaps in a deformity or in an imper- 
fect development of the limb. It is also to be noted that the epiphy- 
ses of the knee, wrist, and shoulder are of especial importance so 
far as the increase in length of the bones is concerned, because they 
are the last to join the shaft and the growth in them is consequently 
continued the longest. The striking growth of a small centre of 
ossification in the course of five or six years is quite remarkable. 
Hammond has done such excellent work regarding the epiphyses 
in this connection that I shall quote from his results quite freely. 

Shoulder. — In connection with the epiphyses of the shoulder 
the upper epiphysis of the humerus is found as a dome-shaped mass 
which appears to rest lightly on top of the shaft. It is composed of 
the centres for the head and for the greater and lesser trochanters, 
which unite to form this epiphysis presumably at about the fifth 
year, according to the old chronologic method of determining de- 
velopment. The epiphyseal line lies a little way above the surgical 
neck, and is not horizontal, but is higher in the middle of the shaft 
than at the outer and inner sides. The increase in length of the 
humerus takes place principally at this epiphysis, and hence its great 
importance. 

Elbow. — The lower epiphysis of the humerus at the age of five 
or six years shows merely a small, round, bony mass, the centre for 
the capitellum. At twelve or thirteen years, however, the centres 
for the trochlea and the external epicondyle have appeared and have 
united with the centre for the capitellum, forming the lower epiphy- 
sis. In an anteroposterior view of the elbow this is seen as a wedge- 
shaped mass, its lower surface being convex, and lying below the 
external condyle. The internal epicondyle is not a part of the lower 
epiphysis of the humerus, but is formed from a separate centre of 
ossification. In a Roentgenograph it appears as a small, oval mass 
higher up on the inner side of the humerus and intimately con- 



THE EXTREMITIES. 177 

nected with the internal condyle. The epiphysis of the head of the 
radius is seen as a small, flat disc lying just above that bone. In a 
lateral view of the elbow at about five years chronologically the 
lower epiphysis of the humerus appears to be semilunar in shape, 
fitting closely the lower end of the shaft. The lower end of the 
humerus is bent forward so that at times the epiphysis appears to 
be slightly displaced. The epiphyseal line may appear as a cleft 
either at the front or at the back of the humerus, instead of a uni- 
form line running all the way between the shaft and the epiphysis. 
This is quite confusing at times, as the epiphysis appears to be 
displaced either forward or backward. In these cases it is only by 
having a Roentgenograph of the normal joint that we can deter- 
mine whether the epiphysis is separated. It is always well to have 
a Roentgenograph of the normal joint in all cases, but it is especially 
necessary in injuries to the elbow. The ray should strike the part 
at the same angle in each case, so that we view both elbows as 
nearly as possible under exactly the same conditions, otherwise an 
injured epiphysis may be overlooked, or a normal epiphysis may be 
mistaken for a separation. In the lateral view the picture of the 
internal epicondyle is usually merged with that of the internal 
condyle, or may be seen partly overlapping it. The epiphysis of the 
head of the radius is seen above that bone, and the epiphysis of the 
upper end of the ulna lies above the olecranon. This latter epiphy- 
sis is an irregular, rounded or three-sided bony mass, and from its 
location and appearance is often called the patella of the arm. 

Wrist. — In connection with the wrist it is well to note that the 
epiphysis of the lower end of the radius is sometimes mistaken for 
a Colles's fracture. In an anteroposterior view it appears wedge- 
shaped and is thicker on the outer than on the inner side of the wrist. 
The epiphyseal line, though irregular and wavy, is never rough and 
jagged as in a fracture. Colles's fracture also is always found at a 

12 



178 THE ROENTGEN RAY IN PEDIATRICS. 

higher point on the shaft. This epiphysis has a great share in the 
increase in length of the radius. The epiphysis of the lower end of 
the ulna is situated at a slightly higher level than that of the radius 
and shows the prominence of the styloid process on its inner side. 
This epiphysis, though not commonly injured, is important because 
the increase in length of the ulna takes place almost entirely from it 
and any injury to this epiphysis may lead to serious deformity of the 
forearm, wrist, or hand. The epiphyses of the four inner metacar- 
pal bones are situated at the distal end of the shafts, but in the 
phalanges and in the metacarpal bone of the thumb (which latter 
is to be regarded morphologically and developmentally as a pha- 
lanx) the epiphyses are found at the proximal ends of their respec- 
tive shafts. In a lateral view of the wrist the epiphysis of the ulna 
is seen to be at a distinctly higher level than that of the radius. 

Hip. — The epiphysis of the upper end of the femur includes 
merely the articular head of the bone and forms no part of the neck. 
In a Roentgenograph it sometimes resembles in appearance the 
epiphysis of the upper end of the humerus. Both the greater and 
lesser trochanters arise from separate centres of ossification, but 
these are less frequently shown in the Roentgenograph than is the 
larger epiphysis. 

Knee. — The epiphysis at the lower end of the femur is the 
largest epiphysis in the body, and is probably the one most fre- 
quently injured. It is the only epiphysis in which bone is formed 
before birth. In an anteroposterior Roentgenograph it is seen to be 
a large, irregular, bony mass, forming the entire lower end of the 
femur. The epiphyseal line is seen at the level of the abductor 
tubercle on the inner side. Its outline is wavy, rises rather sharply 
toward its centre, and has a slightly lower level at the outer side of 
the bone. In this view also are seen the upper epiphyses of the 
tibia and fibula. The epiphyseal line of the tibia somewhat resembles 



THE EXTREMITIES. 179 

that of the lower end of the femur just above it. The upper epiphy- 
sis of the fibula is a small mass appearing to rest lightly on the top 
of the shaft. In the lateral view of the knee the epiphyseal lines of 
the femur and fibula are nearly horizontal. The epiphysis of the 
upper end of the tibia in this view is seen to have a tongue-like 
projection extending down the front of the bone to the tubercle of 
the tibia. Sometimes this tongue-like process does not reach so 
far as the tubercle, and the latter is seen developing from a separate 
centre of ossification. Its importance has increased since the Roent- 
gen ray has shown it to be rather frequently the seat of injuries 
which present somewhat vague clinical signs and symptoms. 

Ankle. — The lower epiphyses of the tibia and fibula are seen 
in an anteroposterior view of the ankle. The epiphyseal line is 
nearly horizontal in the case of both bones, but that of the fibula is 
at a lower level and comes opposite the ankle-joint. The internal 
malleolus forms the inner portion of the lower tibial epiphysis, and 
the external malleolus is practically entirely composed of the lower 
epiphysis of the fibula. This latter epiphysis is greatly concerned 
in the increase in length of the fibula. 

Os Calcis. — The os calcis has an epiphysis on its posterior sur- 
face, just below the attachment of the tendo Achillis, and is seen as 
a small, oval disc. This is to be remembered in studying Roentgen- 
ographs of the foot in childhood. 

The epiphysis at the inner end of the clavicle, those of the 
acromion and coracoid processes of the scapula, and those of the 
ribs, vertebrce, and pelvic bones are of no practical importance and 
would rarely cause confusion in studying a Roentgenograph. 

Hammond concludes his most valuable and interesting study 
of the normal epiphyses by saying that in injuries of the joints in 
childhood the outline at the different stages of development should 
always be remembered and the normal Roentgenographs should be 
familiar to every one. 



180 THE ROENTGEN RAY IN PEDIATRICS. 

Young children, especially infants, are very susceptible to in- 
flammations in the region of the joints whenever infection occurs, 
and the younger the individual the more apt is a joint to be involved. 
The small joints of the wrist, knee, and foot show the greatest sus- 
ceptibility to infection. Pyogenic organisms may enter at the 
umbilicus or through the intestinal tract and give rise to arthritis 
.of the joints, as may also the infecting organisms of influenza, and 
the pneumococcus or the gonococcus. The infecting organism of 
rheumatic fever has a special predilection for the joints, and the 
bacillus of tubercle finds a favorable site for growth in the joints. 
Congenital syphilis very frequently attacks the joints. Age not only 
makes a difference as to the susceptibility of infection of the joints, 
but it is to be noted that the tissues around the joints are more 
liable to infection in infants than in older children. It has also been 
noted that children under five years of age are much less apt to have 
suppurative conditions in the region of the joints. When they occur 
in children over five years of age the infection is either tuberculous 
or rheumatic. Shortly after birth the infections most frequently 
met with are those due to sepsis, and somewhat later, though still 
during the early months, they are due to the gonococcus. These 
infections are apt to be multiple. To repeat somewhat, the infec- 
tive agent may be the streptococcus, the staphylococcus, the pneu- 
mococcus, the bacillus of typhoid, the bacillus of influenza, and 
occasionally the colon bacillus. In regard to the infections which 
involve the joints themselves certain infections of the bone occur 
in infants and young children, and also in the cellular tissues adja- 
cent to the joints, which at times give rise to swelling and to those 
symptoms found in actual involvement of the joint. Osteomye- 
litis, periostitis, epiphysitis, and deep cellulitis may often occur 
near the joints and extend into the joint-capsule. On the other 
hand, infections beginning in the joint may quickly involve the 



THE EXTREMITIES. 181 

tissues around the joint and these may become more inflamed than 
the joint itself. This follows the rule of probable infection in the 
epiphysis according as the age of the individual and the degree of 
breadth of the cartilage of the epiphyseal line is greater or less. 

If the inflammation is acute it is somewhat difficult to make 
a diagnosis, as the local signs are very similar, whether the infecting 
agent is the streptococcus or some other organism. If the inflam- 
mation is of the subacute or chronic type it is more likely to be 
due to the bacillus of tubercle or to the gonococcus. If the infec- 
tion involves only one joint, or perhaps shows moderate reaction, 
the probability is that the organism is the bacillus of tubercle. 

It may be said in regard to the infection of the hip-joint that 
Konig's collection of infections of this joint shows that there were 
560 caused by the bacillus of tubercle and 110 by other organisms 
producing acute infection. 

The infection of the epiphyses represents a characteristic pic- 
ture. The knee is the most common seat of the infection, but the 
epiphyses of any of the bones may be attacked and the infection 
may be single or multiple. The characteristic appearance is shown 
in Plate 198. There is swelling and thickening of the tissues around 
the joint, and the epiphyseal line is thickened and filled in. The 
density is increased around the epiphysis and the diaphysis. The 
joint is not involved early unless in accordance with the normal 
anatomic relation of the capsules of the joint as described on 
page 169. 

INFECTIOUS ARTHRITIS 

There are a number of inflammatory conditions in the joints, in 
many of which the specific organism has been discovered. There 
are, however, a large number in which the infecting organism has 
not yet been determined, but the process is considered by analogy 
and comparison to be caused by an organism. We know that the 



182 THE ROENTGEN RAY IN PEDIATRICS. 

bacillus of tubercle is one of the organisms which primarily attacks 
the joints. We also know that the various organisms which may 
give rise to the general disease osteomyelitis, such as the strepto- 
coccus and staphylococcus, though they primarily attack first the 
shaft of the bone, yet often involve the joint. This depends on 
whether the capsule of the joint is inserted into the epiphysis 
itself or into the zone of proliferation. As instances of other causes 
of infectious arthritis are the pneumococcus, the organism of rheu- 
matic fever, the gonococcus, and the etiologic factors of scarlet 
fever and measles. These foci of infection may be in any part of the 
body, as in the tonsil or in the ear. The arthritis may be due to 
the presence of a specific organism in the joint, or to the action of 
its toxins. In the former case the local process is more severe. ' It 
is thus seen that under the general term infectious arthritis should 
be included a very large number of diseases. Arthritis may be 
caused by a primary infection from an original focus, or through 
some portal of entrance, such as the tonsils, or it may be an accom- 
panying condition of certain general diseases, such as scarlet fever, 
typhoid fever, syphilis, epidemic influenza, erysipelas, cerebro- 
spinal meningitis, gonorrhoea, glanders, the infectious diarrhoeas, 
and a number of others. In making a pathologic diagnosis by the 
Roentgen ray in these infections we should seek to determine the 
specific lesions which characterize the special disease and the organ- 
ism causing it. In the past it has been extremely difficult to accom- 
plish this, as the post-mortem findings as I have said before almost 
invariably teach us only terminal results. It is well known, however, 
that the same terminal results may represent a number of primary 
conditions, the lesions of which differ very materially according to 
the specific infecting organism. It will in the future, therefore, by 
means of the Roentgen examination be possible to determine during 
life primary lesions and conditions and thus complete our knowledge 



THE EXTREMITIES. 183 

of the various inflammations of the bones and of the joints. It is 
now pretty well accepted, from what we have learned by inves- 
tigating diseases of the joints by means of the Roentgen method, 
that etiologically they are all infections, whether we have poly- 
articular disturbance or that of a single joint; also that these infec- 
tions through some direct portal or from some definite focus are 
transmitted by the blood usually to the most highly organized ana- 
tomic areas, and that the infection takes place in an especial tissue, 
according to the predilection of the special organism for that tissue. 
Of course where the lesions are symmetrical, we should consider 
etiologically the possibility of trophic conditions. Infectious arthri- 
tis, therefore, may be the result of any of the infections or pus- 
producing organisms. The severity of the attack depends not upon 
whether the joint is the primary seat of the lesion, but upon the 
special organism, and upon its virulence, whether it is actually present 
in the joint, and also upon the idiosyncrasy of the individual child. 
When we come to consider the more chronic processes in the joints, 
the determination of a satisfactory classification is difficult. From 
what we have learned, however, by studying these processes on the 
living subject we are led to believe that these chronic conditions, 
which are when examined post mortem in most cases terminal 
conditions, are produced by the primary infection of specific organ- 
isms. This in the future will probably prove to be true when it is 
possible to determine the especial infecting organism. As instances 
of the chronic form of arthritis, for we can call these also arthritis, 
since the term infection implies inflammation and since by this 
term we understand reaction with cellular infiltration, are the 
chronic conditions represented by hypertrophy and atrophy of the 
tissues of the joints. The examination by the RoentgeD method 
will in the future present to us the early lesions of these diseases in 
the living subject, but it at present merely shows that cenain Condi- 



184 THE ROENTGEN RAY IN PEDIATRICS. 

tions exist at various stages of the tissue changes. Thus the Roent- 
genograph can show what in children is a secondary condition, 
namely, a villous arthritis. Again, the picture may show a swelling 
of the soft tissues about the joint, or again atrophy of the bony 
and cartilaginous parts. It may show hypertrophic changes in the 
bones and cartilages of the joints, Heberden's nodes, the urates of 
soda, and the deposits of gout. It is also to be noticed that atrophy 
of the surrounding soft tissues as an end result of ankylosis of the 
joint commonly occurs. 

Although details of the examination by the Roentgen method 
are not by any means completely developed, or in fact thoroughly 
understood, still it is well known by expert Roentgenologists that 
certain definite pathologic facts are being continually demon- 
strated in these cases. The change which occurs in the joint is 
that of an increased blood supply. It is demonstrated in all of 
these cases, if seen early, that there is an increase, usually in the 
size of the bone, as is shown in the plate. If the knee-joint is 
infected the condyles will be increased in size in comparison with 
the opposite side. The epiphysis of the fibula if not already devel- 
oped will appear earlier than on the unaffected side, and it is 
evident that this inflammation is due to a definite organism. 

It is well to again enunciate the importance of bearing in mind 
that in children, especially in young children, the acute lesion of the 
bone is usually at the beginning an epiphysitis or a periostitis, and 
not an osteomyelitis, for the bone-marrow is not involved. The pus 
ceases to spread in bone or cartilage when once it has any other 
direction in which to spread, and it ceases to dissect up the peri- 
osteum when it can escape in any other direction. Hence in young 
subjects, in contradistinction from the later periods of development, 
the pus, having a freer vent into the line of the epiphyseal cartilage, 
does not so frequently attack the medulla, bone, and periosteum. 



THE EXTREMITIES. 185 

Humerus: Infectious Arthritis, Atrophy of Shaft. — Plate 203 rep- 
resents a case of infectious arthritis in a child and shows a marked 
atrophy of the shaft of the humerus, this atrophy being both of 
size and of quality. The outlines of the cortex and the medulla in 
the shaft are distinctly marked. The special infecting organism 
was not ascertained in this case. The child according to the ana- 
tomic age should be placed in Group F or G. 

Plate 204 represents the hands of the same case. These hands 
show the finely pencilled outlines of the bones. There is no absolute 
destruction of tissue, but simply absorption. The joint substances 
are not as yet disturbed. In the left hand there is a slight delay in 
the development of the carpal bones. There is also a slight amount 
of inflammation of the tissue in both joints. 

Hand: Infectious Arthritis. — Plate 205 shows a case of infectious 
arthritis with the organism not determined, showing itself in the 
hand of a boy four and a half years old. The second and third 
metacarpal bones show some thickening of the periosteum along the 
shaft. The third metacarpal bone also shows two small areas of 
absorption of the lime salts. There is only a very slight inflam- 
mation of the tissues shown by decreased radiability in the palm 
of the hand. There is a thickening of the tissues about the wrist- 
joint. The carpal bones are a little larger than normal and their 
structure is somewhat effaced. 

The carpal bones are a little larger than normal, show less 
bony structure. 

Knee: Effusion. — Plate 206 shows a lateral view of an effusion 
in the knee-joint of a boy ten years old. There is no disturbance 
of the femur, tibia, or fibula, excepting in the posterior aspect of the 
condyles of the femur, which are a little ragged. The patella has a 
few excrescences of bone on its superior border. This is probably 
due to irregular ossification. The tissues about the joint seem to be 



186 THE ROENTGEN RAY IN PEDIATRICS. 

thickened as well as to contain fluid. The fluid is differentiated 
from the density of the knee-joint by the ballooning character of 
the density as well as by the space occupied by the subpatella fat 
pad, which is absent in this plate. It will be noticed that the liga- 
mentum patellae is pushed upwards and that it is convex on its 
anterior surface. 

Femur: Infection — Non-tubercular. — Plate 207 shows the de- 
struction of the head of the right femur from some septic infection, 
the specific organism of which was not determined, but in all proba- 
bility was not tubercular. 

Rheumatic Fever — Knee. — Plate 208 represents the left knee-joint 
of a case of rheumatic fever. In this case there was acute swelling, 
pain, and fever, and the Roentgen plate taken early in the attack 
showed slight thickening of the capsule. The reproduction, however, 
shows nothing abnormal and the illustration is merely given here to 
show how difficult it is to detect in some of the acute infections 
of the joints any pathologic process whatever. 

Rheumatic Fever — Ankle. — Plate 209 shows the joint of the ankle 
of the same subject. Here also there was swelling, tenderness, and 
fever, and the case clinically seemed to be one of rheumatic fever. 
In this case the Roentgenographic plate also showed thickening of 
the capsule of the joint, but here also nothing special could be 
detected in the reproduction. 

INFECTIOUS PERIOSTITIS 

The diagnosis of an early infection of the periosteum by means 
of the Roentgen ray is attained principally by recognizing certain 
pathologic changes, such as thickening and bulging of the peri- 
osteum. Usually the line of the periosteum is less distinctly seen, 
particularly that of the normal bone. Again the periosteum may 
be seen to be broken and ragged, exposing the cortex. 



THE EXTREMITIES. 187 

OSTEOMYELITIS 

Although the disease osteomyelitis has been recognized for a 
number of years, yet we now have a much more definite knowledge 
of it than in the past. We know that it is not caused by any one 
special organism, but that it is a general term which covers a num- 
ber of specific infections, and simply means that, instead of special 
organisms affecting the periosteum, the cortex of the bone and the 
medullary cavity are also affected. Now that the Roentgen ray has 
been brought to bear upon this general class of infections, and a 
special study has been made of these different organisms in connec- 
tion with their infection of the bones, a great advance has been made 
in our knowledge of the living pathology of osteomyelitis. For this 
reason also the primary pathologic conditions in the bones in early 
life have become more prominent, as they show at that period the 
actual pathology, while at a later period the postmortem in many 
cases only shows terminal results. These terminal results may some- 
times be characteristic of the special infection, but more often may 
represent conditions which are the result of a number of entirely 
different infectious organisms. 

The type of infections which are grouped under the name osteo- 
myelitis makes it in some respects the most important disease 
of the bones which occurs in early life. This is true on account 
of the tremendous destruction of bone which may occur, either 
terminating in death or in various degrees of deformity which 
may be permanent. The rapidity of the onset and the resulting 
rapid destruction of the bone give osteomyelitis a place in dis- 
eases of the bone which appendicitis holds in diseases of the 
abdomen. In the case of appendicitis delays in operation may 
mean death. In osteomyelitis, delay in diagnosis and in operative 
treatment may mean not only death, but resulting deformities 
which cannot be rectified, and in some cases may mean more than 



188 THE ROENTGEN RAY IN PEDIATRICS. 

death. It is therefore important that an early diagnosis should be 
made of this class of cases, and that operative treatment if indicated 
should be decided upon at once. To accomplish this early diagnosis, 
the Roentgen ray is of inestimable value, for at times it tells us what 
the clinical examination fails to find. 

Osteomyelitis is a general disease so far as its etiology is con- 
cerned, but in many cases it can only be diagnosticated surely by 
the Roentgen ray. Among the numerous organisms which may 
cause it, the most prominent is the staphylococcus in the chronic 
cases of low grade, while in rapidly septic cases the streptococcus is 
most commonly found. In certain cases the pneumococcus occurs 
and produces a fairly chronic condition, and finally the bacillus of 
typhoid may cause either an acute or chronic process. 

I shall merely enunciate the fact that the Roentgen ray should 
be used at once during the earliest period of the symptoms, and that 
we should not be led astray in our diagnosis by thinking that the 
case may be one of rheumatic fever. There is more confusion in the 
mind of the general practitioner in regard to rheumatic fever in con- 
nection with this set of cases than arises when a differential diagnosis 
is to be made from any other disease. For this reason the organism 
which may be producing an osteomyelitis has an opportunity to 
thoroughly infect the bone, and often to such an extent that opera- 
tive treatment becomes of little avail. This is especially the case in 
very young children, where the percentage of cases caused by infec- 
tions of the epiphyses is very great. 

As in other severe diseases of the bone, it is difficult to make a 
definite diagnosis of osteomyelitis unless the case is examined by 
the Roentgen method. When the Roentgenograph is used, how- 
ever, the difficulty is very greatly lessened. 

Infectious osteomyelitis may be single or multiple in its first 
appearance, and in its course may be acute, subacute, or chronic. 



THE EXTREMITIES. 189 

An involvement of any of the bones may occur, but the knee is the 
most common seat of infection. The tissues usually show swelling 
and thickening, the epiphyseal line is thickened and filled in, and 
the radiability surrounding the epiphysis and diaphysis is increased. 
The infection commonly attacks the long bones, and it is usually the 
extremities of the bones which are involved. According to the site 
of the infection and of the tissues involved, the primary infection may 
be of the periosteum or of the marrow. When the infection is seen 
early by the Roentgen ray the principal pathologic change is found 
in the periosteum. The change consists of thickening and hyper- 
trophy of the periosteum with its line less distinctly seen. Again 
the periosteum may be thickened and ragged, exposing the cortex. 
When the infection is of the marrow the Roentgenograph shows 
very early in the process the infected area to be represented by 
one or more definite degrees of density, varying in size from a pin- 
head to several times that size. There is also found, at times, an 
increased area of radiability in which the structure of the bone 
is being destroyed and absorption of the lime salts is probably 
taking place. 

Osteomyelitis, as distinctive from tuberculosis or syphilis of the 
bone, is shown by a more definite proliferation of the periosteum, a 
more definite formation of new bone in the area of necrosis, or this 
area may show large pieces of bone which have not been absorbed. 

In the subacute and chronic cases of osteomyelitis the struc- 
ture of the bone shows less distinctly and is accompanied by atrophy 
below the point of infection. This atrophy is not particularly in 
size, but rather in quality, and is accompanied by an excessive 
amount of proliferation of the periosteum. At times the process 
goes so far, as is shown in Plate 210, Fig. 2, that there is a definite 
area of exposed bone surrounded by an involuenmi. 

Tibia: Early Stage. — Plate 210, Ki,i. r . I, represents the knee of a 



190 THE ROENTGEN RAY IN PEDIATRICS. 

child nine years old, showing one of the earliest manifestations of 
osteomyelitis. The child was kicked on the tibia, the injury having 
taken place two days before being seen. The Roentgenograph was 
taken on the third day and showed an increased radiability of bone 
about one inch below the epiphyseal line of the tibia. Below this 
there was a slightly boggy periosteum running down almost the whole 
length of the tibia, especially in front, and showing evidently an ex- 
udation of fluid under the periosteum, proved later by operation 
not to be blood. The clinical symptoms were extreme pain, swelling, 
no fluctuation or redness, tenderness, and a varying temperature. 

Tibia: Same Case, Later Stage. — Plate 210, Fig. 2, shows a later 
stage of the same case. Owing to a delay in making a correct diag- 
nosis, an operation was postponed until infection had taken place, 
and the process went on to such an extent that the whole bone 
became involved. The plate shows proliferation of the periosteum, 
with formation of sequestra. 

This case was evidently one of simple trauma in the beginning, 
and if it had been recognized that an early infection had taken place 
operative treatment would have been very simple and would have 
preserved the leg from the extensive lesions shown in the Roent- 
genograph. 

Femur. — Plate 211 represents the leg of a child ten years old who 
entered the hospital for rheumatic fever. The clinical symptoms 
were referred to the knee, where there was swelling and tenderness, 
but nothing localized was detected in the lower part of the femur. 
The Roentgenograph showed increased radiability of the diaphysis 
of the femur with proliferation of the periosteum. The operation 
was delayed too long and the infection went so far that the disease 
lasted for over a year. Several operations had to be performed for 
the removal of the sequestra, and although the child finally recov- 
ered it was left with irreparable deformity. 



THE EXTREMITIES. 191 

Femur. — Plate 212, Fig. 1, is the picture of a child twelve years 
old. The Roentgenograph of this case shows the permanent results of 
acute osteomyelitis of the left femur. It was treated for tuberculosis 
of the hip. All of the destruction took place within two or three 
months. An early operation would have obviated this result. In the 
course of the differential diagnosis the process was aspirated and the 
infection was proved to be from the staphylococcus. 

Hip. — Fig. 2 is the picture of a child five years old. There was 
a history of swelling in the region of the right hip with slight limita- 
tion of motion and pain about the hip. It was sent to the hospital 
with a diagnosis of tuberculosis of the hip. The Roentgenograph 
showed an infiltration, with the formation of an abscess resulting from 
infection of the neck of the femur. There was proliferation of the 
periosteum about midway between the greater and lesser trochanter 
and epiphyseal line. There was here also an area of increased radia- 
bility. The infection was so completely outside of the capsule of the 
joint that the case was evidently not one of tuberculosis but of 
osteomyelitis. 

Tibia. — Plate 213, Fig. 1, represents a case of osteomyelitis of the 
tibia in a boy eight years old. In this picture it will be seen that 
the capsule and soft parts about the right knee are thickened. The 
femur is comparatively normal, as is also the fibula, but at the upper 
end of the tibia there is seen to be an area of destruction of the bone 
with a formation of sequestrum. The epiphyseal line, as well as the 
epiphysis, is involved in the destructive process, which starts in the 
epiphyseal line of the tibia. Operation was delayed and the process 
extended into the epiphysis. This case shows how important it is 
to recognize the very early lesions of an osteomyelitis. This could 
have been done if the Roentgen method of examination had been 
employed at once. 

Tibia: Bone Plug. — Fig. 2 shows the same case. An operation 



192 THE ROENTGEN RAY IN PEDIATRICS. 

was performed later and a bone plug inserted in the cavity. The 
Roentgenograph illustrates that the operation must necessarily be a 
failure for there is a sequestrum still remaining in the cavity. The 
tibia shows below the point simply absorption of the lime salts, 
which is also seen in the fibula, in both cases there being a lessened 
radiability. This Roentgenograph is a striking illustration of the 
great use of the ray, not only in detecting the nidus of the disease, 
and its early portrayal of destruction of the tissues, but also how 
a series of pictures will aid the surgeon by elucidating why his 
operation is a failure. 

Femur. — Plate 214 represents a case of acute infectious osteo- 
myelitis in a girl two and a half years old, twelve hours after the 
onset of the first symptoms. There is a haziness of the outline of 
the right femur with marked inflammatory reaction of the soft parts 
about the thigh. The process went on, as is shown in Plate 215, to 
a general destruction of the entire shaft of the femur. This plate 
illustrates how early changes in the tissues and bones can be dem- 
onstrated by the Roentgen ray. 

Femur: Plate 215 shows the same case as Plate 214, but five 
weeks later. In the middle of the shaft is an area of inflammation; 
somewhat lower, and on the outer edge of the bone, there is newly 
formed periosteal tissue. Further down in the upper part of the 
diaphysis is the point of attachment of the capsule and periosteum 
to the shaft of the femur. It is to be noticed that the joints have 
not yet become infected, but that the infection of the bone is con- 
fined within the limits of the periosteum. There was a considerable 
reaction of the soft parts not shown in this plate but clearly seen 
in the original plate. All the other bones shown in the picture are 
normal. 

Elbow. — Plate 216 is the picture of a boy nine years old, with 
osteomyelitis of the elbow. There is seen to be marked atrophy 



THE EXTREMITIES. 193 

in the quality of the bones, but not in the size. The epiphyses of 
all the bones in the elbow, but especially of the radius and of the 
ulna, are almost completely eroded and the joint is filled with 
necrotic material. 

Humeri. — Plate 217 shows marked destruction of both humeri 
in a boy eight years old. The whole structure of the bone and peri- 
osteum of the upper half of both bones is seen to be markedly in- 
volved. There is active destruction with formation of sequestra at 
both upper ends. The joints of both shoulders are affected. The 
head of the bone on the right is more involved than on the left. The 
lower ends of the humeri on both sides show a marked increase in 
radiability. The thorax is normal. The infecting organism was 
found to be the bacillus of typhoid. 

Radius. — Plate 218 represents an osteomyelitis of the lower 
third of the radius in a boy six years old. The soft tissues are greatly 
thickened. There is marked thickening of the periosteum on the 
lower half of the radius, with a general necrosis of the bone in the 
lower third, and with the formation of a sequestrum at both points. 
There is an almost complete separation at the lower end of the 
radius. The epiphyseal line is involved and the proximal surface of 
the epiphysis is roughened. 

Radius. — Plate 219, Fig. 1, represents the photograph of a child 
with acute osteomyelitis of the radius. There is seen to be a con- 
siderable swelling of the soft parts of the wrist and of the whole 
lower arm, starting at the bend of the elbow. 

The Roentgenographs, Figs. 2 and 3, do not show periosteal 
reaction on account of the destruction of the bone. The lower two- 
thirds of the radius seems to be almost completely a mass of necrotic 
material. The upper part of the radius seems to be out of place. 
The surface of the joint of the elbow is apparently not infected. 
The two carpal bones that are present are not involved. 

13 



194 THE ROENTGEN RAY IN PEDIATRICS. 

Hip. — Plate 220 shows an acute infectious arthritis in a child 
two and a half years old. The soft tissues around the left hip are 
seen to have a greater density than on the right. The shaft of the 
femur shows slightly increased radiability, and the radiability of 
the epiphysis is also marked. The primary focus of the disease in 
this case is in the acetabulum, where at the junction of the ischium 
and ilium there is a marked destruction. There is a small formation 
of sequestrum at this point. 

Hip. — Plate 221 shows a marked increase in the radiability of 
the soft tissues around the hip-joint in a boy seven years old. The 
epiphysis of the greater trochanter is irregular and partly absorbed. 
The medullary canal at the upper end of the femur shows marked 
absorption of lime salts; periosteal reaction and proliferation are 
strongly marked. The epiphyseal line is seen to be very ragged, 
although there is no actual destruction at this point. The lower 
portion of the acetabulum is also roughened. 

Femur. — Plate 222 represents the results of an infectious osteo- 
myelitis of the upper part of the femur, occurring in a girl three 
and a half years old and produced by the pneumococcus. The soft 
tissues appear to be rather hazy, but of increased radiability, and 
indicate an inflammatory action. Just outside the capsule of the 
joint and in the region of the surgical neck of the femur there is 
seen to be an area of destruction of bone with the formation of a 
sequestrum. The line of demarcation at the lower end of the in- 
volved area is clearly outlined. There is a slight increase of peri- 
osteum along the upper line of the femur. The head of the femur 
and the acetabulum are perfectly normal. No apparent decrease in 
the lime salts is shown. 

Femur. — Plate 223 shows a marked disturbance in the neck of 
the femur in a girl four and a half years old. There is an almost 
complete absorption of lime in this area and marked periosteal 



THE EXTREMITIES. 195 

thickening at the upper end of the femur on both sides. There is 
apparently no involvement of the epiphyseal line, but there is a 
marked inflammatory reaction of the soft parts around the greater 
trochanter. This infection was due to the staphylococcus. 

Hip- joint. — Plate 224 shows a mixed infection of the hip- joint 
in a girl six years old. The soft parts around the right hip-joint are 
seen to be greatly thickened and the density is much increased. 
The shaft of the femur shows no atrophy of size, but a slight one of 
quality. The neck and epiphysis of the femur, however, are almost 
completely destroyed or absorbed. The acetabulum also is mark- 
edly affected. There is thickening of the periosteum along the 
iliopectineal line. The rami of the os pubis and ischium show the 
same process. There is a partial dislocation. 

Tibia. — Plate 225 represents osteomyelitis of the lower end of 
the tibia in a boy twelve years old. It is to be noted that there is 
an area of necrotic bone which is surrounded by a dense zone of new 
bone formation which walls the process completely off. This Roent- 
genograph illustrates the condition which occurs in a low grade of 
staphylococcus infection. 

Femur. — Plate 226 is the picture of a boy seven years old with 
osteomyelitis of the right femur. To be noted is the slight amount 
of swelling in the soft parts around the right knee-joint. The lower 
end of the femur is larger in size than the left femur, and shows along 
its inner edge an absorption of lime salts. There is hypertrophy in 
addition to absorption. The epiphysis of the right femur shows 
an irregular deposit characterized by its ragged appearance. The 
primary focus of the infection is seemingly in this epiphysis. 

Tibia. — Plate 227 represents osteomyelitis of the left tibia at 
its upper end in a boy twelve years old. The picture shows a marked 
proliferation of the periosteum of the upper third of the tibia, with 
numerous sequestra. An operation showed this to be a staphy- 
lococcus infection. 



196 THE ROENTGEN RAY IN PEDIATRICS. 

Tibia: Early Stage of Infection. — Plate 228 shows a practically 
normal tibia and foot except at one point in a boy twelve years old. 
At the lower end of the tibia close to its epiphyseal line there is a 
small area with increased radiability. This condition shows an early 
stage of osteomyelitis. 

Fibula. — Plate 229 is the picture of a girl eleven years old with 
osteomyelitis of the fibula. It will be seen that the periosteum of 
the fibula is greatly thickened and that in the lower third there is 
also quite an area of increased radiability, which is the focus of the 
infection. It will also be seen that there is a beginning rim of new 
formation of bone around this area, nature's process of walling off. 
The other bones in this picture are normal. 

Tibia. — Plate 230 shows an undetermined infection of the 
lower epiphysis of the tibia in a boy ten years old. The structure 
of the bone is perfectly normal except at the point of infection. 
At this point in the epiphysis of the tibia there is a small area of 
increased radiability. As yet there is no atrophy of any of the 
bones of the foot. 

Tibia. — Plate 231 shows a case of chronic infectious osteo- 
myelitis in a boy six years old. The soft tissues around the knee- 
joint are shown to be greatly thickened. The epiphyseal line of the 
tibia is ragged and irregular with some increase in radiability. Along 
the inner margin of the upper end of the tibia there is a beginning 
destruction of the bone. The femur and fibula simply show slight 
increased radiability. 

HYPERTROPHIC AND ATROPHIC PROCESSES OF THE JOINTS 

The chronic hypertrophic conditions of the joints which occur 
in later life are very rare in early life. The pathologic condition 
which is most common in this chronic class of cases in early life is 
represented by an atrophic condition of the joints. It is a slow, 
progressive disease, and most commonly manifests itself in some of 



THE EXTREMITIES. 197 

the smaller joints, usually in the proximal row of the phalangeal 
articulations. At first one or more joints are affected, but grad- 
ually other joints become involved until in many instances every 
joint of the body is included in the destructive process. The prog- 
ress of the disease lasts for a period of years. A great deal of work 
has been done by different investigators on this subject, but I shall 
not attempt to discuss the subject of classification here, as we are 
simply interested in what we may expect to see in the Roentgeno- 
graphs of these cases. 

The chronic atrophic cases show a swelling of the soft tissues 
about the joints due to synovial fluid, and subsequent atrophy of 
the cartilaginous parts of the bones. The Roentgen ray is especially 
valuable in these cases for the purpose of differentiating them from 
certain forms of infectious arthritis, where there are spindle-cell 
swellings but where the ray shows there is not the characteristic 
atrophy. 

Chronic Atrophic Wrists, Hands, Arms, Knees, Legs, and Ankles. 
— Plate 232 represents the hands of a boy, showing a chronic 
atrophic condition of the joints of the wrists and hands. There 
is marked atrophy of the forearm, with considerable fusiform swell- 
ing in the carpal region as well as in the third and fourth fingers 
of the right hand and the first, second, third, and probably the 
fourth of the left hand. Clinically this was a case of infectious 
arthritis followed by atrophy. 

Plate 233 shows the knees of a boy eight years old. There is 
marked thickening about the knee-joint, contrasting with the extreme 
atrophy of the leg. The same condition of the knee-joint will be 
noticed in the Roentgenograph; all the bones of the body were 
affected in a similar way. 

Knee: Chronic Atrophy. — Plate 234 shows a Roentgenograph 
of the same boy. It is to be noted that the bone substance is more 



198 THE ROENTGEN RAY IN PEDIATRICS. 

compact and smaller than normal, and that there is an atrophy of 
the substance of the muscles. The joint itself is partly involved 
and the surfaces of the joint are seen to be greatly roughened, espe- 
cially the epiphysis of the femur. The cortex is very sharply de- 
fined. The patella shows an atrophic condition with increased 
radiability. The outline of the articular surface of the condyles is 
irregular, and is due in part to the irregular ossification of the sub- 
stance of the bone, as well as to some disease, as shown by erosion. 
There is also thickening about the joint but no fluid. There is 
marked atrophy of the femur, tibia, and fibula, not only of size but 
also of quality, and characterized by finely pencilled cortical bone 
seen in all the bones. There is a sharp outline of the condyles and of 
the epiphysis of the tibia. There is fine trabeculation of the bone, 
and the patella shows fine pencilling. 

SYPHILIS 

The lesions of syphilis which can be shown in Roentgenographs 
are mostly of the osseous tissues. Although all the organs of the 
body may be affected by the Spirochseta pallida, yet the special 
lesions by which the diagnosis of the disease can be made when the 
Roentgen method is employed are essentially those of the bones. 
The living pathology of the lesions of the bones differs according to 
whether we are dealing with a case of congenital syphilis, which 
corresponds to the secondary symptoms of acquired syphilis, or with 
the retarded and later form of syphilis in childhood, which corre- 
sponds to the tertiary lesions of acquired syphilis. In the former case, 
the congenital, we find that the Roentgenograph shows the picture 
of an acute epiphysitis and its accompanying periostitis, leading 
later to separation of the epiphyses and to pseudoparalysis, simu- 
lating also in many cases fracture. To those who are not especially 
acquainted with the many ways in which syphilis simulates other 
diseases, these lesions of the bones are apt to be misleading. I have 



THE EXTREMITIES. 199 

seen cases where a separation of the epiphysis of the wrist in young 
infants has been mistaken and treated for a fracture, the thickened 
periosteum being mistaken for a callus. In such cases as these 
the Roentgen method aids us to make a differential diagnosis. The 
lesions which are mostly to be confounded with syphilis of the 
bones are those of tuberculosis. It is in these cases which are often 
obscure that special means for a differential diagnosis should be 
employed. By means of the Roentgenograph we can distinguish 
the destruction of the cortex of the bone and the primary lesions 
occurring in the joint in tuberculosis from the marked thicken- 
ing of the periosteum, layer on layer, significant of syphilis. 

In syphilitic lesions of the osseous system which occur in children 
there are at first disturbances of the periosteum with marked perios- 
teal overgrowth and much laying down of new bone. Usually 
changes in shape occur more along the middle of the shaft of the 
bone than near the epiphyses. The overgrowth of periosteum is 
out of all proportion to what would be expected from simple perios- 
titis, or without any change in the bone excepting an increase of 
the cortex. 

The close simulation of syphilitic dactylitis and tubercular 
dactylitis makes the Roentgen method of especial value in the 
differential diagnosis of the two diseases. Plate 237 shows a syphi- 
litic dactylitis with its periosteal lesion, and Plate 242 represents a 
tubercular dactylitis with its special destruction of bone. 

Syphilitic Dactylitis. — The differential diagnosis by the Roent- 
gen method shows that in syphilis there is a definite change in the 
exterior of the bone without any change in the interior unless 
suppuration has taken place. The periosteum is thickened and 
increased in size, so that we may have in a phalanx the character- 
istic changes that take place in the long bones. 

Cases have been seen where the condition of one hand was that 



200 THE ROENTGEN RAY IN PEDIATRICS. 

of a syphilitic dactylitis and of the other hand that of a tubercular 
dactylitis. 

The point of diagnosis generally in favor of syphilitic dacty- 
litis and against tubercular dactylitis is that the long bones in 
other parts of the body do not show in tubercular dactylitis dis- 
turbances such as are expected to be found in retarded or congenital 
syphilis. 

Elbow. — Plate 235 represents syphilis in the elbow of a child 
eleven years old. The lower end of the humerus along its inner 
border shows great thickening of the periosteum due to syphilis 
(overgrowth), and it is to be noted that there is no change in the 
shaft of the bone with this exception. There is no change in the 
soft tissues. 

Elbow. — Plate 236, Fig. 1, represents a syphilitic elbow in a girl 
two and a half years old. There is increased thickening of the perios- 
teum along the inner border of the humerus. There is some decrease 
in the lime salts at the lower end of the bone. The greatest area of 
involvement, however, is seen in the ulna, where the periosteum is 
markedly thickened, being almost as thick as the structure of the 
bone itself. On the outer edge of the olecranon there is seen to be a 
beginning destruction of the periosteum. The whole olecranon at 
its upper third is completely changed from its normal structure. 
The radius, however, shows little disturbance beyond the periosteal 
reaction to be expected in this condition. There is a marked in- 
crease in the radiability of all the bones in this plate. 

Ulna. — Fig. 2 represents a syphilitic lower arm in a child four 
and a half years old. There is a very thick layer of periosteum 
on either side of the lower part of the shaft of the ulna. On the 
outer side of the ulna the tissues are thickened and there is a forma- 
tion of abscess in the soft parts. Such a bone as this is absolutely 
characteristic of retarded syphilis. 



THE EXTREMITIES. 201 

Dactylitis. — Plate 237 shows a syphilitic dactylitis in a child 
two years old. There is infection of the first and third metacarpal 
bones and of the first phalanx of the fourth finger. It is to be noted 
that there is very little change in the structure of the bone, but a 
great change is seen in the thickened periosteum. There is con- 
siderable tissue reaction and much fine pencilling of the bone tissue. 

Tibia: Periostitis. — Plate 238 represents a syphilitic periostitis 
of the tibia in a child five years old. There is bulging of the soft 
parts on either side of the tibia and fibula. The periosteum along 
the whole of the tibia, and also of the fibula, is thickened in a char- 
acteristic manner. There is also apparently some thickening of the 
cortical substance. 

Tibia: Periostitis. — Plate 239 shows a syphilitic periostitis of 
the tibia in a child eight years old. This is a lateral view. The out- 
line of the bone along the anterior border of the tibia is slightly more 
convex than normal, with a slight prominence in the upper third of 
the bone posteriorly. On the anterior surface the thickening of the 
periosteum extends along the shaft and down towards the lower 
third. 

Osteoperiostitis and Osteochondritis. — Plate 240 shows a syphilitic 
osteoperiostitis and osteochondritis in a case of congenital syphilis 
in a colored child six weeks old. The infant was breast-fed. When 
four weeks old it developed a pseudoparalysis of the left arm and 
leg, with marked tender swellings at the elbows and knees. There 
was an enlargement of the spleen and liver, and a squamous desqua- 
mation of the soles of the feet and palms of the hands. There were 
fissures at the anus. The enlargement of the upper ends of the tibia 
and fibula, and of the lower ends of the femur, was very much 
marked. The Roentgenograph shows an osteochondritis with in- 
volvement of the diaphyses of the femora and of the tibia and fibula, 
and great thickening of the periosteum. 



202 THE ROENTGEN RAY IN PEDIATRICS. 

Retarded Syphilis, Tibia and Fibula. — Plate 241 was a case of 
retarded syphilis in a child twelve years old. This child had the 
lesions of retarded syphilis in other bones of the body. This plate 
shows the left side of the tibia and fibula. The lower third of the 
tibia shows an area of active suppuration with beginning formation 
of sequestrum. The whole lower part of the tibia is seen to have 
areas of increased radiability. The periosteum is seen to be thick- 
ened along the whole length of the tibia, and of the fibula also. The 
process in the tibia extends apparently down to the epiphyseal line 
but does not involve the ankle-joint. There is also increased radia- 
bility of the shaft of the fibula. The bones of the foot are seemingly 
normal. 

TUBERCULOSIS 

Much has been studied in connection with and much progress 
made in tuberculosis of the lungs, but we should understand that 
of equal, if not greater, importance is a consideration of tuberculosis 
of the bones. 

There are a number of facts which make a study and conse- 
quently a knowledge of tuberculosis of the bones of great importance. 

In order to diagnosticate tubercular conditions and to enable 
us to differentiate tubercular from non-tubercular lesions it is of 
the utmost moment that we should recognize the normal living 
anatomy of the bones at different periods of their development, as 
portrayed by the Roentgen ray. This is especially necessary in 
the early stages of tubercular disease, where the pathologic changes 
are often slight and obscure, and yet where an early diagnosis is 
extremely valuable. This often enables us to arrest the disease by 
treatment, and to determine whether the condition is merely a 
slight anomaly of healthy bone or some non-tubercular affection. 
In both these latter conditions we can often decide that the case 
is not tubercular, and therefore not one to be sent to tubercular 



THE EXTREMITIES. 203 

hospitals or homes. It is also important that the treatment in 
tuberculosis should be begun very early, so as to protect the ear 
and other organs from secondary infection. 

There is no diagnostic means so valuable for the detection of 
tuberculosis of the bones as the Roentgen ray in the hands of experts 
in its technic. Over and over again it becomes a most important 
factor in the chain of evidence which may lead, unless refuted by the 
ray, to stamping an individual as syphilitic, and thus perhaps ruin- 
ing his social life. 

Witness the possible differentiation by the ray of the tubercu- 
lar lesions of the bones from the periosteal lesions of syphilis and 
the especial lesions represented by dactylitis. Again, the importance 
of differentiating by the Roentgen method a non-tubercular from 
a tubercular arthritis, and a tubercular hip from an osteomyelitis 
or an acute trauma, is very great. 

In the past, and very often in the present, many cases have 
been considered and treated as tubercular which have really been 
non-tubercular. The Roentgen method often corrects us when 
we have been mistaken in making a diagnosis of tuberculosis, and 
shows us that if the true diagnosis had been made, an entirely 
different treatment would have been indicated. 

We may tabulate our knowledge of the pathologic findings, 
and understand the terminal lesions at the autopsy; we may make 
advances in the treatment of tuberculosis; but how significant is 
the announcement in the sanatoria that early cases of tuberculosis 
are preferably taken, or often only taken! The diagnosis of these 
early cases, especially where the bones are affected, is exceedingly 
difficult without the aid of the Roentgen ray, even when a thorough 
clinical examination has been made, and especially in those cases 
where the tuberculin test has failed. Most important of all, next 
to the actual operative indications which the Roentgen ray gives 



204 THE ROENTGEN RAY IN PEDIATRICS. 

us, is its differentiation of tuberculosis of the bones in doubtful and 
obscure cases from conditions caused by osteomyelitis, syphilis, 
and trauma. Probably thousands of lives could be saved if cases of 
tuberculosis could be recognized before the later and more advanced 
lesions have appeared, with their almost hopeless prognosis. 

There are certain early lesions in tuberculosis of the bones 
which can be detected by means of the Roentgen ray. One of the 
first manifestations of a tuberculous lesion of the bones is atrophy 
of the shaft of the bone, especially of the femur or of the humerus. 
This may occur long before a definite focus of disease is discernible, 
and this atrophy of size as well as of quality of the bone is noticed 
to increase progressively. 

The infection commonly attacks the epiphyses of the long 
bones, and is first detected by the Roentgen method as a small 
area of increased radiability. This area slowly increases in size and 
shows an atrophy of the bone about the point of infection dispro- 
portionate to the amount of diseased bone apparent. This atrophy 
may be due partly to the infection, but is also due to the slow prog- 
ress of the disease and to disuse of the part. 

The value of the Roentgen ray in detecting diseases of the bones 
is very great, because it indicates the exact location of the infec- 
tion, and the details of the living gross pathology. Primary infec- 
tion of a bone in children by the bacillus of tubercle always occurs 
in the epiphyses except where the child is of an age at which the 
given bone has no ossific centre. The early lesions of tuberculosis 
of the bones which can be detected by means of the Roentgen ray are : 

Atrophy in size of the bone at the upper part of the femur as 
a rule is present. In the joints we find frequently hyper- 
trophy in the early stages followed later by atrophy. 

Atrophy in quality of the substance of the bone. 

A definite area of necrosis of the bone. 



THE EXTREMITIES. 205 

Examination by the Roentgen method shows just at what por- 
tion of the bone the disease begins in a given case, whether in the 
epiphysis or in the diaphysis. It will show also the relative size of 
the diseased areas. It will show the lack of definiteness of the struc- 
ture of the bone which accompanies atrophy, change in quality due 
to an absorption of lime salts, or a disintegration of the bone into 
caseous material. Where a joint is infected by the bacillus of 
tubercle, erosion of the surface of the joint usually begins, by either 
a definite focus at one point or a definite erosion at some portion. 

In cases of tuberculosis of the knee-joint one of the earliest 
manifestations is usually atrophy of the soft parts. In the epiphyses, 
however, there is at first apparent increase in size but atrophy in 
the texture of the bones. There is an increased density in the cap- 
sule, due in all probability to thinning or possibly fluid within the 
joint; there is also squaring and atrophy of the epiphyses. A focus 
may be defined, although in the majority of cases it is not found 
early. We also notice an early stimulation of epiphyseal growth 
and an appearance of hypertrophy of the shaft and of the epiphyses. 
This is usually accounted for by the marked increase of the blood 
supply, which would naturally produce an hypertrophy. This 
accounts also for the increased length of a given part. 

As the process becomes more extensive the characteristic fea- 
tures are generally atrophy of the soft parts, atrophy of the cortex, 
increased density of the cortex, increase of the medullary canal 
at the expense of the cortex, and a lack of definition of the structure 
of the bone. Within the joint affected we find more or less actual 
destruction of bone with detritus about the focus of infection, erosion 
of the surfaces of the joints, increase in the density of the capsule, 
and lack of definition of the structure of the bone generally. 

One of the first manifestations of an infection by the bacillus 
of tubercle is usually atrophy of the size of the bone. This occurs 



206 THE ROENTGEN RAY IN PEDIATRICS. 

long before a definite focus of disease is discernible either by the 
eye or in the Roentgenographs. The epiphyses of the long bones, 
or the acetabulum, are first infected, and this is detected by means 
of the Roentgen ray as a small area or areas of increased radiability. 
This area slowly increases in size and shows an atrophy of the bone 
about the infected point, so that the dense qualities of the bone 
are reduced to that of its surrounding soft parts. 

At times the only noticeable change from the normal is in the 
marked atrophy of size without evidence of destruction of the bone, 
and at times an infiltration of the tissues and capsule with the for- 
mation of an abscess. The bacilli of tubercle do not cause periosteal 
reaction, and when this reaction is seen in the Roentgenograph it 
shows that there has been a mixed infection. 

A point of interest in the examination of a large number of 
cases of tuberculosis in children by the Roentgen method is that 
it demonstrates repeatedly the clinical manifestations of tubercu- 
losis of the joint without definite foci being detected in the bone, 
though a great deal of capsular thickening may be evident. It is 
unusual to find a distinct early necrosis of the bone. 

In the very chronic cases, when examined by the Roentgen 
method, we find the characteristic reconstruction going on to anky- 
losis and to new formation of bone. 

In connection with the differential diagnosis between osteo- 
myelitis and tuberculosis, it is well known that various pathogenic 
infections may result in acute and chronic osteomyelitis. If the 
specific cause of these infections is recognized early, the treatment 
often differs decidedly from that which should be employed where 
the infection is tubercular. By means of the Roentgen method we 
can often localize the pathologic process before the infected area 
has increased very much. We can also almost at once determine 
whether the infection has attacked the bone to any great extent. 



THE EXTREMITIES. 207 

Atrophy. — Atrophy of bone as demonstrated by the Roentgen 
method has become important enough to be spoken of in detail. 
It is evident that three kinds of atrophy are seen, — (1) atrophy of 
size, (2) atrophy of the quality of the substance of the bone, or (3) 
a combination of both. 

It is characteristic that certain organisms produce characteristic 
changes in a bone which are more or less constant. In infection 
of a bone by the bacillus of tubercle, particularly about a large 
joint, such as that of the hip, one of the early manifestations of the 
infection will be a marked atrophy in the size of the femur. This 
is demonstrated long before any actual disease is apparent, unless 
it is a mixed infection. 

Certain authorities have demonstrated by Roentgenographs 
that an atrophy of bones in juxtaposition, such as the os pubis and 
ischium, takes place with an apparent hypertrophy of the ilium. 
In a great majority of these cases misinterpretation may arise re- 
sulting from a deformity of the pelvis brought on by postural or 
structural change which the femur undergoes, due to traction ap- 
plied in carrying out the treatment. Under these circumstances 
the pelvis may be distorted in its relation to the healthy side, so 
that a twist of the innominate bone on the side of the infection, 
whereby the greatest width is brought into view, will give an appar- 
ent atrophy of the os pubis and of the ischium. 

Atrophy of the size of the bone will be evident in the bones 
adjacent to the larger joints. The question has come up repeatedly 
whether atrophy of size is due to a specific disease or to disuse. 
Experimentally, Dr. A. T. Legg claims that atrophy of size is not 
due to disease but to disuse. However, the fact is recognized that the 
osseous and muscular systems of individuals suffering from diseases 
such as general tuberculosis are not able to withstand immobilization 
as well as healthy individuals. It is reasonable therefore to sup- 



208 THE ROENTGEN RAY IN PEDIATRICS. 

pose that a person suffering from tuberculosis, and for some reason 
treated by immobilization of a given part, would have more atrophy 
of the size of the bone than would be evident in an individual who 
was perfectly well having the same amount of immobilization. 

The first change that takes place with immobilization either 
for a fracture or experimentally is the marked re-arrangement of 
the structure of the bone, so that the bone becomes apparently 
porous, the interspaces between the trabecule being demonstrated 
more clearly. Under these conditions the trabeculse stand out a 
little more definitely without any apparent change in size. This 
appearance is typical of the atrophy seen in a foot where there is 
a Pott's fracture, or in a fracture where immobilization has been 
used. In a healthy individual this appearance will progress more 
or less indefinitely. In a person suffering from some constitu- 
tional disease, or infection, where the nutrition of the given part is 
disturbed or has not the equivalent of a healthy individual's blood 
supply, there is on the contrary a change in the natural size of the 
bone with a marked absorption of the structure of the bone. 

Where, for any reason, there is an increased supply of blood 
to a given part, and the case becomes more or less chronic, it is 
demonstrated that the part enlarges or hypertrophies in comparison 
with the healthy and unaffected side. This is seen in chronic osteo- 
myelitis and in chronic synovitis. 

We can have also a combination of both atrophy of quality 
and atrophy of size in which there is a decrease of the size of 
the bone with an absorption of the lime salts. This is seen in the 
chronic forms of arthritis, as well as in tuberculosis of the bone or 
in general tuberculosis. It is also seen in paralytic conditions, such 
as poliomyelitis anterior, and in some of the malignant osteomata, 
where spontaneous fracture takes place usually near the origin of 
the nutrient artery. This fracture usually extends in both directions, 



THE EXTREMITIES. 209 

causing diminution in the size of the bone, and actual absorption 
of the bone substance without any tendency towards the formation 
of a callus. 

Tubercular Dactylitis. — This is a condition in which there is 
a fusiform dactylitis of the fingers or toes, which may attack one 
or more bones in one or both hands. It is characterized in the 
early stage by a beginning destruction about a focus in the interior 
of the bone and sometimes has the appearance of a cystic formation 
of the bone. 

In a later stage of the disease, destruction, or more definitely, 
absorption of the whole interior of the medullary canal of the bone 
takes place with a re-arrangement of the structure of the bone. 
This at times looks as if it were one big cyst or multiple cysts, and 
the bone is larger, and usually has a very thin cortex if any. 

The adjacent joints are not usually affected. This condition 
goes on to thickening, enlarging of the phalanx, and sometimes 
sequestrum in its interior. Suppuration may occur with discharge 
of one or more sequestra, leaving a permanent deformity, usually 
a shortening of the affected finger. Commonly, however, healing 
takes place without much change in the growth. 

Metatarsal Bone. — Plate 242, Fig. 1, represents a destruction of 
cortical bone and a slight cavity in the fourth metatarsal bone 
in a girl twelve years old. The lesions suggest a tubercular process, 
or possibly a benign cyst of the bone. 

Tubercular Dactylitis. — Fig. 2 represents tubercular dactylitis 
in a boy; age, three years; parents healthy. There was no tuber- 
culosis in the family history. The nurse was probably tubercular. 
The child was well until five months old, when a swelling appeared 
in the upper part of the tibia, just below the patella; at this time 
also a swelling of the first phalanx of the middle finger of the right 
hand and the second phalanx of the middle finger of the left hand 
appeared. 

14 



210 THE ROENTGEN RAY IN PEDIATRICS. ' 

Through a misapprehension of the serious nature of the case 
by the physician in charge (who was inclined to make the diagnosis 
of syphilis on account of the dactylitis) nothing especial was done, 
except to live at a sanatorium until January, 1907, when a Roentgen- 
ograph was taken. The true lesions were, therefore, not recognized 
for some time, and in March, 1907, a secondary infection of the 
dorsal vertebrae took place. 

The plate shows a distinct area of destruction of the bone in 
the middle phalanx of the middle finger of the right hand, without 
any evidence of proliferation of the periosteum. The first phalanx 
of the middle finger in the left hand shows the result of a previous 
destructive process, but at the time when the Roentgenograph 
was taken there was new formation of the bone. 

Atrophy from Disuse. — Plate 243 .represents the knees of a 
child twelve years old. A clinical diagnosis of tuberculosis of the 
knee was made in this case, and it was treated as such for two years. 
A series of Roentgenographs of this case were then taken at inter- 
vals, and at no time was any change noticed in the bones which 
would suggest tuberculosis. On the contrary, the marked atrophy 
of the bone and its lessened radiability pointed more to disuse than 
to disease. That is, it was an atrophy of the quality of the bone 
substance rather than the atrophy of size which is characteristic 
of tuberculosis. It was the treatment with a stiff plaster bandage 
which had produced this condition. 

Tubercular Dactylitis. — Plate 244 represents a tubercular dac- 
tylitis occurring in a child two and a half years old. It shows 
the enlargement of the first phalanx of the second and fourth fingers. 
It will be seen that there is a marked change in the structure of the 
bone, also giving it the appearance of a cystic formation, there 
being considerable absorption. It is to be noted that there is very 
little involvement of the periosteum, apparently none. The other 
bones of the hand show in certain areas an osteoporosis. 



THE EXTREMITIES. 211 

Tubercular Dactylitis. — Plate 245 represents a case of tuber- 
cular dactylitis, The soft parts around the infected areas are seen 
to be markedly thickened, the fingers having the spindle-shaped 
appearance. The first and third metacarpal bones are affected, 
and there is marked disturbance of the first phalanx of the fourth 
finger, with apparently an almost cystic formation. It is to be noted 
that there is very little periosteal reaction. In this way it differs 
markedly from syphilitic dactylitis. 

Ulna: Necrosis. — Plate 246 shows an area of necrosis of the bone 
in the lower end of the ulna with a small formation of sequestrum. 
There is also some atrophy of quality. 

Carpal Bones. — Plate 247 represents a tubercular condition 
of the carpal bones of the hands of a child five years old. In the left 
hand (1) it is to be noted that the soft parts are greatly thickened 
and that there is destruction in some of the carpal bones. This 
process was undoubtedly due to a tubercular infection. The right 
hand (2) is normal. 

Elbow-joint. — Plate 248 represents a tubercular process in the 
elbow- joint of a child eight years old. The soft parts show a 
thickening and haziness. The lower end of the humerus shows 
some periosteal reaction, although the contour is regular. The 
ulna on the outer edge of the olecranon shows an area of increased 
radiability, due to absorption of the lime salts and to the gradual 
extension of the tubercular process. The periosteum of the ulna 
is somewhat thickened and the radius shows some decrease in its 
lime salts. 

Hip- joint: Mixed Infection. — Plate 249 represents a tubercular 
hip-joint caused by a mixed infection in a child five years old. 
The density of the soft parts around the left hip is markedly in- 
creased. It will be seen that the shaft of the femur shows a de- 
creased radiability, due to absorption of the substance of the bone. 



212 THE ROENTGEN RAY IN PEDIATRICS. 

The periosteum along the iliopectineal line is greatly thickened. 
This periosteal thickening is probably not due to the bacillus of 
tubercle, but to marked reaction, indicating probably a mixed 
infection. 

Acetabulum. — Plate 250 represents a boy twelve years old show- 
ing marked disease of the whole acetabulum and a mottled appear- 
ance of a decreased radiability. The head of the femur has prac- 
tically disappeared and there is a general involvement of the whole 
neck and greater trochanter, as is also shown by the mottled appear- 
ance. There is practically no tissue reaction to be seen in this plate. 
The shaft of the femur is negative. 

Hip: Mixed Infection. — Plate 251 shows a mixed infection of 
the hip with great involvement of the whole head of the bone and 
destruction of the upper epiphysis of the femur. 

Hip. — Plate 252 represents the result of an old tubercular 
process in the hip of a child fourteen years old. The dotted line 
shows where the head of the femur would naturally be. The acetab- 
ulum is practically destroyed by the disease. There is no regular 
outline, but the process can be seen to be inactive. The femur is 
seen to be ossified to the ilium just above the acetabulum and there 
is atrophy in the region of the greater trochanter. The greater 
trochanter, however, is not to be seen. 

Acetabulum and Femur: Necrosis. — Plate 253 represents a 
tubercular condition of the diaphysis of the femur in a boy eight 
years old. The picture shows a focus of the diaphysis of the right 
femur marked as an area of increased radiability, due to absorption 
of the lime salts and to necrosis of the bone. This area is surrounded 
by a finely pencilled line denoting the formation of new bone, cor- 
responding to nature's effort to wall off the diseased area. The 
epiphysis also shows the presence of disease by its irregular artic- 
ulating surface and the destruction of bone that has taken place. 



THE EXTREMITIES. * 213 

The outline of the acetabulum is also irregular, due to the same 
process. 

Hip. — Plate 254 represents an infectious hip in a child five 
years old. In examining the two hip-joints in this case it will be 
seen in the first place that the soft parts of the left hip- joint have 
a markedly increased radiability. The outline of this increased 
area of density is clearly marked. There is also an area of infection 
in the neck of the right femur. It will be noted in comparing this 
femur with the femur on the other side that there is no atrophy of 
the shaft of the femur nor of the bones of the pelvis. It will be 
seen that the epiphyseal line of the left femur shows lessened radia- 
bility. The epiphysis on the left will be seen to have an increased 
radiability as compared with the right side. The dotted lines on 
the left show diagrammatically the arrangement of the joint-cap- 
sules made by the anterior and the posterior insertions of the cap- 
sule. The dotted lines on the right represent the capsule distended 
with pus. On an earlier examination the disease was noted outside 
of the capsule, but when this picture was taken it had extended 
into the capsule. 

Hip-joint. — Plate 255 represents the picture of tuberculosis of 
the hip-joint in a girl eight years old. There is a marked density 
of the soft parts around the left hip- joint. There is atrophy of both 
size and quality of the shaft of the left femur. There is partial 
absorption of the neck and head of the femur and marked involve- 
ment is shown by the increased radiability and destruction of out- 
line of the acetabulum. There is also atrophy of all the bones of 
the pelvis on this side as compared with the other. 

Knee-joint. — Plate 256 shows an early tuberculosis of the 
knee-joint of a child five years old. There is increased density 
about the knee-joint, which shows thickening of the soft parts and 
capsule. There is a roughening of the epiphysis of the femur with 



214 THE ROENTGEN RAY IN PEDIATRICS. 

as yet no destruction of bone. There is, however, a slight amount 
of atrophy in the shafts. 

Knee-joint. — Plate 257 represents a tuberculous knee-joint 
in a child eight years old. There is a marked thickening of the soft 
parts and of the capsule around the knee-joint. There is atrophy of 
quality as well as of size of the bones. The condyles are irregular in 
outline and there is an irregular development of the patella. The 
epiphysis of the femur is irregular in outline. 

Thigh: Abscess. — Plate 258 shows an encapsulated abscess of 
the thigh in a boy six years old. The lateral view of the thigh shows 
a definitely encapsulated abscess in the anterior lower aspect. The 
tissues around the knee-joint are markedly thickened. The con- 
dyles and epiphysis of the femur are very irregular in outline, as is 
also the upper end of the tibia. There is atrophy of quality as well 
as of size of the femur and also of the tibia and fibula. There is no 
absolute destruction of bone. 

Tibia, Epiphysis. — Plate 259 represents tuberculosis of the 
epiphysis of the tibia. The shaft of the tibia and fibula and the 
epiphyseal line of the tibia are perfectly normal. There will be seen 
a small focus on the posterior aspect of the epiphysis of the tibia. 
There is almost complete absorption of bone in this area. There is 
no formation of sequestrum. The bones of the foot are normal. 

Os Calcis: Abscess. — Plate 260 represents tuberculosis of the 
os calcis in the foot of a child two and a half years old. On the 
dorsum of the foot is a well-defined abscess. The primary focus 
is on the anterior aspect of the os calcis, where there is seen to be 
actual destruction of about one-half of the bone. The other bones 
of the foot show an osteoporosis. 

Ankle and Foot: Abscess. — Plate 261 shows in the ankle-joint 
of a girl four years old a definitely walled abscess consisting either 
of fluid or thickened tissue. The lower end of the tibia shows marked 



THE EXTREMITIES. 215 

absorption of lime salts and increased radiability. The epiphysis 
of the tibia and the astragalus show marked destruction of the 
structure of the bone. They are apparently within the cavity of 
the abscess. The metatarsal bones show the same absorption of 
lime salts as does the lower end of the tibia. There is an atrophy 
of size as well as of quality. The change in quality is shown in the 
os calcis by its finely pencilled outline. The case was probably 
tubercular. 

Ankle: Tuberculosis. — Plate 262 shows a tubercular ankle in 
a child five years old. The soft tissues surrounding the ankle are 
greatly thickened and infiltrated. There is a slight amount of in- 
creased radiability of the tibia as well as of the os calcis. The epiphy- 
sis of the tibia shows an actual destruction in its lower end and an 
involvement of the astragalus on its articulating surface. 

Astragalus and Os Calcis: Tuberculosis. — Plate 263 represents 
a tuberculosis of the astragalus and of the os calcis in a boy twelve 
years old. There is a thickening of the soft parts around the ankle 
and an area of actual destruction of the posterior-inferior portion 
of the astragalus and of the superior border of the os calcis. There 
has been both destruction and absorption. The bones of the foot 
show a finely pencilled outline, as does the lower end of the tibia, 
representing atrophy in quality in these parts, although there is 
no actual involvement. 

NON-TUBERCULAR INFECTIONS 

In the acute pyogenic infections within the joint we have 
classical symptoms of acute infection of the joint, acute onset, 
rapid distention of the joint, much pain, and constitutional dis- 
turbance. 

The subacute or chronic cases of intra-articular pyogenic infec- 
tion may differ in no respect clinically from tuberculosis in its early 
stages, but will clear up much earlier than tuberculosis, with possibly 



216 THE ROENTGEN RAY IN PEDIATRICS. 

a perfect recovery of function. This type, however, may show an 
ultimate permanent lengthening from the irritation of the epiphys- 
eal cartilage. 

Little need be said of the early diagnosis of the acute pyogenic 
infections, except of its importance in demanding operative inter- 
ference. 

In the chronic cases of pyogenic infection with symptoms 
identical with those of tuberculosis of the hip, we should hesitate 
to make a differential diagnosis until, after careful watching and 
repeated Roentgenographs, we could detect the beginning of a de- 
structive process demanding operative interference. 

These particular cases of pyogenic infection resulting in acute 
and chronic osteomyelitis vary in no detail as to our conception 
of osteomyelitis in its pathologic process. According to Legg and 
George it is apparent that these cases are very commonly confused 
with tuberculosis, but if recognized the subsequent early treatment 
will differ radically from that of tuberculosis. The ultimate result 
as to early recovery and as to the function of the part will be, 
however, vastly better. 

In order to recognize this class of cases early we must use all 
the means at our disposal and make a most careful clinical examina- 
tion; the Roentgen ray, however, plays the most important part 
in the diagnosis: 

1. In the location of the pathologic process. 

2. In the early recognition of the extent of the pathologic 

process. 
1. Location. — An infection by a pyogenic organism, though 
it may occur in the epiphysis, is most commonly found in the 
diaphysis, or shaft of the bone, and it will usually be outside of the 
insertion of the joint-capsule and within the boundaries of the 
periosteum. Statistics, however, do not altogether agree with this, 



THE EXTREMITIES. 217 

as Becker states that he has found the ratio of infection in the 
epiphyseal line to be 1 : 4 of that of infection along the shaft. Here, 
again, we have an illustration of how a similar location of the focus 
of a non-tubercular disease may give almost identical clinical signs 
with tuberculosis. But a pyogenic infection may occur along the 
diaphyseal side of the epiphyseal line, in which case, depending on 
the virulence of the organism, the cartilage acts more or less 
successfully as a barrier against the complete involvement of the 
epiphysis or joint. 

It is generally accepted that infection of bone by the bacillus 
of tubercle occurs in the epiphysis in children with rare exceptions, 
and that these are either when the child is under an age in which a 
given bone has no ossific centre, or by direct infection from a focus 
in the epiphysis. 

2. The Roentgen ray shows: 

(1) Apparent infection of the periosteum. 

(2) Apparent infection of the marrow. 

Periosteum. — In acute infections by pyogenic organisms out- 
side of the joint-capsule the infection may start either with direct 
infection of the periosteum, so that we may have the appearance 
of a definite thickening of the periosteum, or with proliferation, or 
as a broken or ragged periosteal outline. 

Marrow. — In infections of the marrow we see in the Roentgen- 
ographs a disturbance of the normal densities of the bone, and an 
area, or areas, varying in size from the smallest possible point to 
half an inch or an inch in diameter. We find that the light easily 
penetrates these points, and we have then the so-called "punched- 
out" appearance, or area of increased radiability. 

In the chronic conditions produced by these pyogenic infections 
we see definite areas of actual destruction of the bone with or with- 
out periosteal reaction, and usually with proliferation of the perios- 



218 THE ROENTGEN RAY IN PEDIATRICS. 

teum. This depends to a certain extent on the proximity to the 
joint-capsule. A formation of sequestrum may or may not take 
place. Commonly the bone is thickened and the periosteum is 
proliferated to a great extent, forming an involucrum about the 
shaft with an area of rarefaction and with sequestrated pieces of 
bone in the centre of these areas. Sometimes the bone becomes 
very dense and only here and there by careful examination can areas 
of rarefaction be detected. Areas of suppuration surround the 
sequestrum. 

Plate 264 is an example of non-tubercular infection mani- 
fested in a child five years old. This case represented a mistake 
in diagnosis. There were classical signs of tuberculosis of the hip, 
and the diagnosis was tuberculosis of the hip. The Roentgenograph 
showed a focus of disease in the neck of the femur, extending to 
the epiphyseal line, but not into the epiphysis. The lesion repre- 
sented a low grade of infection, probably non-tubercular. Tuber- 
culosis very seldom comes primarily in the shaft of a bone. 



PLATE 157. 
RETARDED DEVELOPMENT OF HAND. 

Boy, age 8 years. (Life size.) 

The only carpal bones present are the os magnum, unci- 
form, and semilunar. 

A. Points towards the very slightly developed lower 
epiphysis of the radius. 
The epiphyses of the metacarpal bones and of the phalanges 
are absent. 



Plate 157 










A— 




PLATE 158. 

Age 13 years. (Life size.) 

A. Premature ossification of the lower epiphysis of the radius. 

B. Normal development of the lower epiphysis of the ulna. 

C. Sesamoid bone. 

The other bones are normal. 



Plate 158 




PLATE 159. 
DELAYED DEVELOPMENT OF THE SCAPHOID. 

Boy, age 6 years. (Life size.) 

The arrow points towards a very slightly developed scaph- 
oid. The other bones of the foot are normal. 



Pirate 159 










PLATE 160. 

EARLY OSSIFICATION OF THE UPPER EPIPHYSIS OF THE 

TIBIA. 

(Life size.) 

A. The normal development of the upper epiphysis of the 

fibula. 

B. The early ossification of the upper epiphysis of the tibia 

which has ceased to develop synchronously with the 
fibula. 

C. Early ossification of the lower epiphysis of the femur. 

D. Muscle. 

Note the clear-cut patella to the right. 



Pjlate 160 







PLATE 161. 

CELLULITIS OF TISSUES OF LEFT ARM, FOLLOWING SUBCU- 
TANEOUS INJECTION. 

Boy, age 9 years. (Reduced 37%.) 

A. Infiltrated tissues around the humerus. 

B. Capitellum. 



Pjlate 161 




PLATE 162. 
HEMATOMA OF HEEL. 

Child, age 12 years. (Life size.) 

A. Infiltrated tissues of the heel. 

B. Epiphyseal line of the os calcis. 



Plate 162 




PLATE 163. 

Boy, age 4| years. (Reduced 3Ci-%. ) 

Fig. 1. Roentgenograph of a Giant-celled Sarcoma of the 

Soft Tissues of the Left Thigh. 

Fig. 2. Photograph of the Same Subject. 

The arrow points towards the sarcomatous growth in the 
tissues of the thigh. 



FIG. 1. 



Plate 163 



I 
I 






FIG. 2. 




PLATE 164. 
MEDULLARY SARCOMA OF THE LOWER PART OF THE FEMUR. 

Boy, age about 12 years. 



Plate 164 



PLATE 165. 
PERIOSTEAL SARCOMA— LOWER END OF FEMUR. 

Boy, age 10 years. 

Shows marked proliferation of the periosteum of the lower 
end of the femur with beginning disturbance of the cortex. 



Plate 165 




PLATE 166. 
EXTREME ATROPHY. 

Boy, age 13 years. (Reduced 27%.) 

Cause unknown. 



Plate 166 




i 



PLATE 167. 
ANTERIOR POLIOMYELITIS OF THE RIGHT HAND AND WRIST. 

Infant, age 18 months. (Reduced 15%.) 

1. The left normal hand and wrist. 

2. Marked absorption of the lime salts and consequent increased 

radiability in the right hand. 



Plate 107 



(ill 





% 



PLATE 168. 
ANTERIOR POLIOMYELITIS OF THE LEFT SHOULDER. 

Boy, age 12 months. (Reduced 43S%.) 

The arrow points towards the ill-developed epiphysis of the 
left humerus, and shows the atrophy in size and quality in 
comparison with the right arm. 



Pi, ate 168 




m 



* 



■■ 



■1 



PLATE 169. 
ANTERIOR POLIOMYELITIS OF THE LEFT ARM, 

Child, age 4 years. (Reduced 6%.) 

Decreased density of all the bones. 

The arrow points to the atrophied muscle. 



Plate 169 




PLATE 170. 
SUBPERIOSTEAL HEMORRHAGE OF THE LEFT LEG. 

(Reduced 8l%.) 

A. Points towards the organizing clot, the darker line showing 
almost complete organization. 



Plate 170 



PLATE 171. 
EXOSTOSIS OF ASTRAGALUS. 

Boy, age 12 years. 

The arrow points to the exostosis. 



Plate 171 





PLATE 172. 
MULTIPLE EXOSTOSES OF TIBIA AND FIBULA. 

Boy, age 5 years. (Reduced 21!%.) 

The exostoses are shown at 

A. Inner condyle of femur. 

B. Outer part of fibula. 

C. Lower part of fibula. 



Pjlate 172 



PLATE 173. 
MULTIPLE EXOSTOSES. 

Boy, age 5 years. (Life size.) 

A. Points to exostoses of the lower part of the femur. 

B. Points to an exostosis of the head of the fibula. 

C. Points to an exostosis of the upper part of the tibia. 



Plate 173 



PLATE 174. 

EXOSTOSIS OF THE LOWER PART OF THE FEMUR. 

The arrow points to the exostosis. 



Plate 174 



PLATE 175. 
EXOSTOSIS OF THE TIBIA. 

Boy, age 12 years. (Reduced 38%.) 

The arrow points to the exostosis. 



Plate; 175 




, 






l! 



PLATE 176. 
CALLUSES OF FEET. 

Girl, age 10 years. (Reduced 30%.) (Same subject as Plate 177.) 

The arrows point toward a callus of the scaphoid bone. 



PL ATI] 176 




PLATE 177. 
ABNORMALLY HIGH ARCH OF FOOT. 

Girl, age 10 years. (Reduced 31%.) (Same subject as Plate 176.) 

Arch of the foot abnormally raised by the continuous 
wearing of a bad plate. 



Plate 177 




PLATE 178. 
MODERATE FLAT-FOOT. 

Girl, age 13 years. (Reduced 42%.) 



Pjlate 178 





PLATE 179. 

BACKWARD DISPLACEMENT OF THE INNER CONDYLE OF THE 

FEMUR. 

Boy, age 12 years. (Life size.) 

A. Patella. 

B. Displaced condyle. 

C. Epiphyseal line. 



Plate 179 




PLATE 180. 

FRACTURE AND DISPLACEMENT OF THE HEAD OF THE 

HUMERUS. 

(Life size.) 

A. Head of the humerus. 

B. Shaft of the humerus. 



Plate 180 





PLATE 181. 

DISLOCATION AND FRACTURE OF THE ANATOMIC HEAD OF 

THE HUMERUS. 

Boy, age 11 years. (Life size.) 

A. Epiphyseal line. 



Plate 181 





PLATE 182. 
FRACTURE OF THE NECK OF THE HUMERUS. 

Boy, age 12 years. (Reduced 4%.) 

A and B. Surgical neck of the humerus. 



Plate 182 












PLATE 183. 

IMPACTED FRACTURE OF THE SURGICAL NECK OF THE 

HUMERUS. 

Boy, age 4 years. (Life size.) 

The arrow points to the impaction. 



Pl,ATE 183 




PLATE 184. 
DISLOCATION OF THE EPIPHYSIS OF THE FEMUR. 

Boy, age 5 years (Life size.) 

A. Epiphysis. 

B. Irregular diaphysis. 

C. Callus. 
0. Patella. 



Plate 184 



/ 



PLATE 185. 

UNTREATED BUT UNITED GREEN-STICK FRACTURE OF THE 

TIBIA. 

Boy, age 8 years. (Reduced 33i% ) 

A, B, and C point to region of the fracture. 

A. Thickening at the point of the old fracture. 

B. Thickened cortex. 

C. Increased density of the medullary portion of the shaft. 



Plate 185 




PLATE 186. 
INTRACAPSULAR FRACTURE OF THE FEMUR. 

Boy age 10 years. (Life size.) 



Plate 186 



■B 



Hi 




PLATE 187. 
DISLOCATION OF THE LOWER END OF THE FEMUR. 

Boy, age 10 years. (Life size.) 

A. The condyle dislocated backward. 



Plate 1ST 




PLATE 188. 

FRACTURE OF THE LOWER END OF THE HUMERUS, WITH 
INWARD DISPLACEMENT OF THE LOWER FRAGMENT. 

Boy, age 10 years. (Life size.) 

A. Lower end of humerus. 

B. Epiphyseal line of capitellum with humerus. 

C. Epiphysis of the olecranon process. 

D. Epiphysis of radius. 

E. Capitellum. 

F. Tin splint. 



Plate 188 





k — 



PLATE 189. 
GREEN-STICK FRACTURE OF THE RADIUS. 

Girl, age 12 years. (Reduced 7fc%.) 

The arrow points to the fracture. 

The arm was taken bandaged in a splint. 



Plate 189 




41 



PLATE 190. 

COMPLETE FRACTURE OF THE LOWER THIRD OF THE RADIUS 
AND ULNA, WITH IMPACTION. 

Child, age 3 to 4 years. (Life size.) 

A. Impaction of the radius. 

B. Impaction of the ulna. 



Plate 190 



w 






i 






PLATE 191. 
COMPLETE FRACTURE OF THE RADIUS AND ULNA. 

Age 3 years. (Reduced 8%.) 

A. Fracture of the radius. 

B. Fracture of the ulna. 

C. Capitellum. 



Plate 191 




fc 



I 




PLATE 192. 
INCOMPLETE FRACTURE OF THE LOWER END OF THE TIBIA. 

Infant, age 12 months. (Life size.) 

A. Fracture. 

B. Showing rupture of the tendo Achillis. 



Plate 192 







PLATE 193. 
FRACTURE OF THE ASTRAGALUS. 

Boy, age 11 years. (Life size ) 

A and B indicate the line of fracture. 



Plate 193 



i 




/ 




PLATE 194. 

OLD FRACTURE OF TIBIA AND FIBULA, WITH CONNECTING 
BRIDGE AND FORMATION OF ABSCESS OF THE ANKLE. 

(Life size.) 

A. Bridge. 

B. Formation of the abscess of the tissues of the ankle. 



Plate 194 








PLATE 195. 
NORMAL FOOT. 

Child, age 10 years. (Reduced 12%.) 



Shows the epiphysis of the os calcis developing from two 
centres, which clinically appeared to be a fracture. 

The arrow points to the two ossific centres of the os calcis. 



Plate 195 




PLATE 196. 

FRACTURE OF TIBIA WITH COMPENSATORY GROWTH OF 

FIBULA. 

Girl, age 12 years. (Reduced 43J%.) 

A. Points towards ununited fracture of the tibia. 

B. The very much increased cortical bone of the fibula. Note 

the marked increase in density of the whole fibula on 
the left side, and the marked decrease of radiability of 
the lower end of the femur and of the tibia of the left leg. 



Plate 196 



PLATE 197. 
CONGESTION OF THE KNEE IN A CASE OF CHRONIC ARTHRITIS. 

Child, age 6 years. (Life size." 1 

A. Points to the slight capsular thickening and the enlarged 

epiphyses of the femur and tibia. 

B. Points to the epiphysis of the fibula which from irritation 

has developed sooner than on the right side. 

C. C, C. Remains of the epiphyseal lines in an earlier stage of 

development. 



Plate 197 




B 




\ 



\ 



PLATE 198. 
EPIPHYSITIS OF THE KNEE-JOINT. 

Boy, age 1 year. (Life size.) 

The arrow points towards the diaphysis of the femur which 
is markedly irregular. 



Plate 198 








PLATE 199. 
EPIPHYSITIS OF THE UPPER EPIPHYSIS OF THE TIBIA. 

Girl age 10 years. (Life size.) 

A. Points to the early ossification of the epiphysis of the 
tibia. 
Notice the increased length of the fibula arising from its 
continued growth after the growth of the tibia had been arrested. 



Plate 199 




PLATE 200. 
INFECTIOUS ARTHRITIS, ATROPHIC TYPE. 

Girl, age 3 years. (Life size.) 

Note the general osteoporosis. 

A. Points towards the cortex of the femur which, though 

lessened in size ; shows very much more definitely than 
a normal cortex at this age. 

B. Points to the general capsular thickening. Note the 

irregularity of the outline, as well as the structure of 
the condyles (epiphyses). 



Platf, 200 




I 



?$k ■ 







PLATE 201. 
VILLOUS ARTHRITIS. 

Girl, age 12 years. 



Note the general enlargement of the condyles of the femur, 
with considerable thickening of the tissues about the knee-joint. 



Plate 201 







PLATE 202. 
ANKYLOSIS OF KNEE-JOINT. 

Boy, age 13 years. (Life size.) 

A. Patella. 

B. Abnormal arrangement of the trabecule of the bone. 

D. The bony bridge between the condyle and the epiphysis of 

the tibia. 

E. The remains of the epiphyseal line in the upper portion of 

the tibia. 

F. The remains of the epiphyseal line in the lower end of the 

femur. 
Note in this instance how the structure of the bone is con- 
tinuous through the condyles. 



Plate 202 




PLATE 203. 
INFECTIOUS ARTHRITIS IN SHOULDER-JOINT. 

Girl, age 8 years. (Reduced 13J%.) (Same subject as Plate 204 ) 

Somewhat hypertrophied epiphysis of the upper extremity 
of the humerus, with atrophy of the shaft of the bone, both in 
size and quality. 



Plate 203 






PLATE 204. 
INFECTIOUS ARTHRITIS OF HANDS. 

(Same subject as Plate 203 ) (Reduced 26*%.) 

Notice the very definite increased density of the cortex of 
all the bones of both hands with rarefaction of the epiphyses 
and somewhat thickened tissue about the carpus. 



Plate 204 




PLATE 205. 
INFECTIOUS ARTHRITIS OF THE HAND. 

Boy, age 4J years. (Life size.) 

A. Points to a periosteal reaction along the shaft of the third 

metacarpal bone. 

B. Points to the same condition in a less degree in the second 

metacarpal bone. 
The proximal portions of these two bones show slight necro- 
sis and a considerable thickening of the tissues in the region of 
the carpal bones. 



Plate 205 





PLATE 206. 
EFFUSION IN THE KNEE-JOINT. 

Boy, age 10 years. (Reduced 13*%.) 

Note the definite outline of the density of the capsule. 



Plate 206 





■ 



PLATE 207. 
ACUTE ARTHRITIS OF RIGHT HIP. 

Age 8 months. (Reduced 20%.) 

The arrow points towards the head of the femur, which 
shows evidence of a destructive process that has destroyed the 
epiphysis and part of the neck, causing a dislocation of the 
femur. 

Non-tubercular destruction of the head of the bone. 



Plate 207 




J 







PLATE 208. 
RHEUMATIC FEVER— KNEE-JOINT. 

(Reduced 36%.) (Same subject as Plate 209.) 

The lesions are evident only in the original Roentgen plate. 



Plate 208 



PLATE 209. 
RHEUMATIC FEVER— ANKLE-JOINT. 

(Reduced 19%.) (Same subject as Plats 208.) 

The lesions are evident only in the original Roentgen plate. 



Plate 209 







\ 



PLATE 210. 
OSTEOMYELITIS OF THE SHAFT OF THE TIBIA. 

(Archiv. Pediatrics, July, 1907.) 

Fig. 1. The Tibia of a Child Nine Years Old. 

The arrow points towards a few small areas of increased 
radiability. 

Fig. 2. The Same Subject as Fig. 1 Three Months after 
First Plate was Taken. 
Shows marked proliferation of the periosteum with invo- 
lucrum formation about the whole shaft of the tibia. 



Plate 210 



FIG. 1 



FIG. 2. 






PLATE 211. 
CHRONIC OSTEOMYELITIS OF THE SHAFT OF THE FEMUR. 

(Archiv. Pediatrics, July, 1907.) 

The arrow points towards the formation of an involucrum 
of the whole shaft of the femur with the formation of a 
sequestrum. 

Note the extreme osteoporosis of the upper parts of the 
shaft and of the epiphyses of the tibia and fibula. 



Plate 211 





PLATE 212. 

THE RESULTS OF AN ACUTE DESTRUCTIVE PROCESS IN THE 

HIPS. 

(Archiv. Pediatrics, July, 1907.) 

Fig. 1. Acute Osteomyelitis of the Head of the Femur. 
The arrow points towards an actual loss of the epiphysis 
and part of the neck of the femur, with irregularity of the 
acetabulum due to an early acute non-tubercular infection. 

Fig. 2. Infection of the Neck of the Femur. 
The arrow points towards an abscess. 



FIG. 1. 



Plate 212 




FIG. 2. 










s 




PLATE 213. 

OSTEOMYELITIS OF THE UPPER SHAFT OF THE TIBIA AND OF 
THE EPIPHYSIS. 

(Archiv. Pediatrics, July, 1907.) 
Boy, age 8 years. 

Fig. 1. Necrosis with formation of sequestrum in the shaft and 
somewhat in the epiphyses. 
The arrow points towards the necrotic area. 

Fig. 2. The arrow points to an area of actual necrosis within 
the upper shaft of the tibia as well as in the epiphysis. 
The very dense area partly within the diaphysis and partly 

within the epiphysis is a plug. 



FIG. 1. 




Plate 213 



FIG. 2. 




PLATE 214. 
ACUTE OSTEOMYELITIS OF THE RIGHT FEMUR. 

Child, age 2J j'ears. (Same subject as Plate 215.) 

Shows an area of decreased radiability of the subcutaneous 
tissue and swelling of the muscles of the right leg. The outline 
of the bone is hazy. The cortex is not so well defined as normal. 
No disturbance of the epiphyses. 




Plate 214 

~~1 



I 



PLATE 215. 

CHRONIC OSTEOMYELITIS— GREAT DESTRUCTION OF THE 

FEMUR. 

Age 2\ years. (Same subject as Plate 214. Taken 5 weeks later.) 

1. An area of suppuration. 

2. Newly formed periosteal bone. 

3. Necrotic cortical bone. 

The arrows show points of attachment of the capsule and 
periosteum. The shaft of the femur, the hip- and the knee- 
joints are not involved; the infection is confined within the 
limits of the periosteum. 



Plate 215 




PLATE 216. 
OSTEOMYELITIS OF ELBOW. 

Boy, age 9 years. (Life size.) 

Shows considerable destruction with new formation of bone 
within the joint. 

A. Rarefaction of the shaft of the humerus. 



Plate 216 





PLATE 217. 
TYPHOIDAL OSTEOMYELITIS. 

Child, age 8 years. (Reduced 58i%.) 

The arrows point towards the humeri, which show marked 
disturbance of the shafts due to necrosis and new formation of 
bone. 



Pi, ate 217 




PLATE 218. 
OSTEOMYELITIS OF THE LOWER END OF THE RADIUS. 

Boy, age 6 years. (Reduced 17%.) 

A. Involucrum about shaft, with the beginning formation of a 
sequestrum. 



Plate 218 




PLATE 219. 

OSTEOMYELITIS. 

Fig. 1. Photograph of the Arm. 

Shows swelling along the dorsal surface of the forearm and 
hand. 

Fig. 2. Chronic Osteomyelitis of the Lower Part of the 
Shaft of the Radius, with Actual Loss of 
Most of the Shaft. 

A. Points to an outline of thickened tissue. 

B. New formation of bone. 

C. The end of the shaft. 

D. The carpus. 

Fig. 3. Roentgenograph taken Two Weeks Later. 
A. Points to an outline of thickened tissue. 

D. The carpus. 

E. New formation of bone. 



FIG. 1. 



Plate 219 




FIG. 2. 



FIG. 3. 






PLATE 220. 
OSTEOMYELITIS OF ACETABULUM WITH SEQUESTRUM. 

Child, age 2\ years. (Reduced 17%.) 

The arrow points to a sequestrum in the region of the 
acetabulum of the left hip. 

About the hip-joint is seen an increased area of density 
which is an abscess within the capsule. There is also some 
atrophy of the quality of the epiphysis. 



Pjlate 220 




PLATE 221. 
OSTEOMYELITIS OF FEMUR. 

Child, age 7 years. (Reduced 12%.) 

A . Area of density around the region of the capsule, significant 

of abscess within the joint. 

B. Absorption of the diaphysis. 

C. Slight destructive process of the great trochanter. 
E. Slight destructive process of the great trochanter. 

D. Some porosity of the femur. 



Plate 221 




PLATE 222. 

OSTEOMYELITIS NEAR THE HIP-JOINT— PNEUMOCOCCUS 
INFECTION. 

Child, age 3i years. (Life size.) 

A. An area of increased radiability characterized by absorption 
and formation of a sequestrum within the shaft of the 
bone. 



Plate 222 




i 



PLATE 223. 
OSTEOMYELITIS NEAR HIP-JOINT. 

Child, age 4J years. (Life size.) 

Staphylococcus infection of the neck of the femur. 

A. An area of increased radiability due to a destructive 
process within the bone. Greatly thickened 
periosteum of the upper third of the femur. 



Plate 223 




PLATE 224. 
MIXED INFECTION OF HIP-JOINT— PROBABLE OSTEOMYELITIS. 

Girl, age 6 years. (Reduced 32%.) 

A. Thickened periosteum within the cavity of the pelvis along 

the iliopectineal line. 

B. Marked absorption of the neck and head of the femur; 

rough and irregular outline of the acetabulum; consid- 
erable thickening of tissue about joint; femur dislocated. 



Plate 224 




PLATE 225. 
OSTEOMYELITIS OF LOWER END OF TIBIA. 

Boy, age 12 years (Life size.) 

A low grade of staphylococcus infection. 

A. An area of increased radiability showing absorption and 
destruction of the tibia. 



Plate 225 







PLATE 226. 
OSTEOMYELITIS OF THE LOWER END OF THE RIGHT FEMUR. 

Boy, age 7 years (Reduced 15^%.) 

The arrows point to a process in the lower end of the femur 
which is characterized, in the plate, by a marked increased 
radiability both of the diaphysis and somewhat of the epiphysis. 



Plate 226 





PLATE 227. 
OSTEOMYELITIS OF THE UPPER END OF THE LEFT TIBIA. 

Boy, age 12 years. (Life size.) 

The arrow points towards a marked periosteal proliferation 
and an actual necrosis of bone of the upper third of the tibia, 
with a multiple formation of sequestrum. No apparent dis- 
turbance of the epiphyses. 



Plate 227 





PLATE 228. 

EARLY STAGE OF OSTEOMYELITIS OF THE LOWER EXTREMITY 

OF THE TIBIA. 

Boy, age 12 years. (Reduced 12%.) 

The arrow points to an area of increased radiability of the 
lower diaphysis of the shaft of the tibia. 



Plate 228 




PLATE 229. 
OSTEOMYELITIS OF FIBULA. 

Girl, age 11 years (Life size.) 

The arrow points towards the lower third of the fibula in 
which there is a marked periosteal overgrowth and some actual 
bone necrosis. 



Plate 229 




PLATE 230. 

UNDETERMINED INFECTION OF THE LOWER EPIPHYSIS OF 

THE TIBIA. 

Boy, age 10 years, (Life size ) 

The arrow points towards an area of increased radiability 
in the posterior aspect of the epiphysis of the tibia. 



Plate 230 







i 




PLATE 231. 

CHRONIC INFECTIOUS OSTEOMYELITIS OF THE UPPER END 

OF THE TIBIA. 

Boy, age 6 years. (Life size.) 

A. Points towards a general thickening and infiltration about 

the knee-joint. 

B. The area of actual necrosis and disturbance of the bone in 

the shaft and along the epiphyseal line. 
Note the atrophy in quality of the epiphyses. 



PLATE 231 



PLATE 232. 

Fig. 1. Photograph of the Hands of a Boy 12 Years Old. 

Fig. 2. Roentgenograph of the Same Hands. 

Note in the left hand the marked atrophy of quality as 
well as of size of all the bones; considerable roughening and 
irregularity of the carpus and thickening of the tissues. 



FIG. 1. 



Pilate 232 




FIG. 2. 




PLATE 233. 
CHRONIC ATROPHIC CONDITION OF THE KNEE-JOINTS. 

Boy, age 8 years. 

Photograph of the same subject as Plate 234. 



Plate 233 




PLATE 234. 

AN INFECTIOUS ARTHRITIS OF THE KNEE-JOINT, SHOWING A 
CHRONIC ATROPHIC CONDITION. 

(Same subject as Plate 233.) (Life size.) 

A. Points to marked pencilled outline of femur due to very 

dense cortical bone. 

B. The roughened articular surfaces of the femur, due to 

some erosion of the joint surfaces. 

C. Points to the area of poorly developed patella. 



Plate 234 



B 





PLATE 235. 
SYPHILIS OF LOWER END OF THE HUMERUS. 

Boy, age 11 years. (Life size.) 

Arrow points towards marked periosteal overgrowth along 
the inner border of the humerus. There is no destruction of 
the bone. 



Plate 235 




PLATE 236. 

Fig. 1. Syphilis of the Elbow. Girl, age 2\ Years. (Life 

SIZE.) 

A. Points to marked periosteal overgrowth, with an area of 

destructive process. 

B. Very dense new bone-forming periosteum. 

C. Outline of the original bone. 

Note that there is no actual destruction of the ulna. 

Fig. 2. Syphilis of the Forearm. Girl, age 4J Years. 

A. Points to marked periosteal reaction. 

B. Shaft of ulna. 

C. Thickening of tissues, probably due to abscess. 



Plate 236 



FIG. 1. 




a 



\ \ 



\ 



FIG. 2. 







C ► 



ft 

\ 



PLATE 237. 
SYPHILITIC DACTYLITIS. 

Child, age 2 years. (Life size.) 



Characterized in the plate by periosteal overgrowths, A. B, 
C, D, with no apparent disturbance of the bone itself. 



Plate 237 



vt 

I 






PLATE 238. 
SYPHILITIC PERIOSTITIS. 

Child, age 5 years. (Reduced 6%.) 

A. Slight thickening of tissues along crest of tibia. 

B. Slight thickening of the periosteum along crest of tibia. 

C. Slight thickening along fibula. 



Plate 238 



PLATE 239. 
SYPHILITIC PERIOSTITIS IN SHAFT OF TIBIA. 

Boy, age 8 years. (Reduced 23%.) 

A and B point to thickened periosteum. 



Plate 239 




PLATE 240. 
SYPHILITIC OSTEOPERIOSTITIS AND OSTEOCHONDRITIS. 

Child, age 6 weeks. (Life size.) 
[Patient of Dr. L. E. La Fetra.] 

Plate shows extreme proliferative process along the shafts 
of all the bones of the leg, with evident formation of bone in the 
region of the diaphyses, as well as multiple areas of necrosis. 



Plate 240 








PLATE 241. 
SYPHILIS OF LOWER END OF TIBIA. 

Girl, age 12 years. (Reduced 6%.) 

A. Points to areas of increased radiability due to marked 

absorption of the lime salts, with an effort towards new 
formation of bone. 

B. Considerable periosteal proliferation. 

C. Thickening of the periosteum. 



Plate 241 







— 




i 



PLATE 242. 

Fig. 1. Girl, Age 12 Years. Questionable Process in the 
Fourth Metatarsal Bone. 
Characterized by marked new bone formation around the 
shaft of the metatarsus. 

Fig. 2. Child, Age 3 Years. Tubercular Dactylitis. 

Shows a distinct area of destruction of the bones of the 
middle phalanx of the middle finger of the right hand, without 
any periosteal reaction. 

The second phalanx of the middle finger of the left hand 
shows result of a previous destructive process. 



FIG. 1 



Plate 242 




FIG. 2. 



W 



V 



ill 



* 




i 




PLATE 243. 
ATROPHY OF KNEE FROM DISUSE. 

Girl, age 12 years. 

Shows marked osteoporosis of the left femur and tibia; 
squaring of the epiphyses, with some destruction at point of 
arrow. Atrophy of quality of the bones. 



Plate 243 





*^ 




PLATE 244. 
TUBERCULAR DACTYLITIS. 

Girl, age 2J years. 



The first phalanx of the second and third fingers show 
marked enlargement of the shaft, with re-arrangement of the 
structure of that bone resembling cyst-formation. 



Plate 244 





PLATE 245. 
TUBERCULAR DACTYLITIS. 

Child, age 3 years. (Life size.) 

The first and third metacarpal and the first phalanx of 
the fourth finger show marked enlargement, deformity, and 
destruction of bone tissue. 



Plate 245 




PLATE 246. 

TUBERCULOSIS OF THE LOWER PART OF THE SHAFT OF THE 

ULNA. 

Child, age 3 years. (Life size.) 

The arrow points towards an area of actual absorption and 
a necrosis of the bone with a small sequestrum. 

Note that the ulna has no developed epiphysis. 



Plate 246 





PLATE 247. 
TUBERCULOSIS OF THE CARPAL BONES. 

Boy, age 5 years. (Reduced 24%.) 

1. The arrow points towards an evident necrosis of the carpus 

with considerable thickening of the tissue. 

The inflammatory condition has caused a more rapid devel- 
opment of the carpal bones and the presence of one more bone 
than appeared in 2. 

2. Normal hand. 



y 



4 i I 



Plate 247 



I// \ \ W 



i 








PLATE 248. 
TUBERCULOSIS IN ELBOW-JOINT. 

Girl, age 8 years. (Life size ) 

A. Humerus. 

B and C. Area of increased radiability of the olecranon proc- 
ess of the ulna within the joint. 
D. Radius. 



Pi, ate 248 




PLATE 249. 
PROBABLE MIXED INFECTION OF HIP-JOINT. 

Child, age 5 years. (Life size.) 

A. Periosteal proliferation within the pelvis. 

B. Marked infiltration and thickening of tissue. The head 

and neck of the femur show a general porosity; beginning 
dislocation of the femur. 



Plate 249 







PLATE 250. 
TUBERCULOSIS OF THE FEMUR AND ACETABULUM. 

Boy, age 12 years. (Life size.) 

This plate shows the end result of a long-standing tuber- 
cular process of the femur and acetabulum, with actual loss 
of the head and neck of the femur, and development of a wan- 
dering acetabulum. 

A. Acetabulum. 

B. Remains of the neck. 

C. Great trochanter. 



Plate 250 




PLATE 251. 
MIXED INFECTION OF THE HIP-JOINT AND ACETABULUM. 

Child, age 5 years. (Life size.) 

A. Characterized by actual loss of substance of the acetabu- 

lum and epiphysis of femur. 

B. Considerable thickening of the neck and shaft, with an 

unusual amount of periosteal proliferation about the 
neck and shaft of the bone. 



Plate 251 




B 



PLATE 252. 
THE END RESULT OF AN OLD TUBERCULAR PROCESS. 

Child, age 14 years. (Reduced 5%.) 

A. Diagrammatically represents the region of the normal 

head of the femur and acetabulum. There has been an 
actual loss of the epiphysis and of the neck of the femur 
in this case. 

B. Points to the greater trochanter. 



Plate 252 




PLATE 253. 
PROBABLE TUBERCULAR INFECTION OF THE EPIPHYSES, 

Child, age 8 years. (Life size.) 

A. Points to an area of bone necrosis of the epiphysis and 

neck of the femur. 

B. Points to the roughened acetabulum. 

C. Points to the very irregular and porous epiphysis of the 

femur. 



Plate 253 




PLATE 254. 
AN INFECTIOUS PROCESS IN THE NECK OF THE FEMUR. 

Child, age 5 years. (Reduced 24%.) 

The arrow points to an abscess within the left hip-joint, 
with considerable porosity of the epiphysis of the femur, and 
actual destruction of the neck. No atrophy of the shaft of the 
femur. 

A and B. Diagrammatically represent the attachment of 
the capsule of the right hip-joint. 



Plate 254 




PLATE 255. 

TYPICAL TUBERCULOSIS OF THE LEFT HIP-JOINT, CHARACTER- 
IZED BY MARKED POROSITY OF THE WHOLE LEFT SIDE. 

Girl, age 8 years. (Reduced 28%.) 

A. Actual loss of the substance of the head of the femur. 

B. Actual loss of the substance of the acetabulum. 

C. Extreme atrophy of the shaft of the bone, in both quality 

and size. 



Pirate 255 



i 




PLATE 256. 

QUESTIONABLE INFECTION OF THE KNEE-JOINT, CHARACTER- 
IZED SIMPLY BY AN INFILTRATION OF THE TISSUES. 
PROBABLY TUBERCULOSIS. 

Boy, age 5 years. (Life size.) 

A. Points to the infiltrated tissues. 



Plate 25G 





PLATE 257. 
TYPICAL TUBERCULOSIS OF THE KNEE-JOINT. 

Boy, age 8 years. (Life size.) 

A. Points to increased amount of fluid and tissue within the 

capsule. 
B and C. The irregular developing patella. 
D. The condyles, which show very irregular formation. 



Plate 257 





PLATE 258. 
ABSCESS OF THE THIGH. 

Boy, age 6 years. (Reduced 34%.) 

The arrow points to an increased area of density along the 
anterior aspect of the thigh — probably hematoma from trau- 
matism. 



Plate 258 




PLATE 259. 
TUBERCULOSIS OF THE EPIPHYSIS OF THE TIBIA. 

Child, age 9 years. (Reduced 16%.) 

The arrow points towards an area of actual necrosis of 
the bone. 



Plate 259 





PLATE 260. 
TUBERCULOSIS OF THE OS CALCIS. 

Child, age 2J years. (Reduced 10%.) 

The lower arrow points to a marked necrosis of the bone 
of the body of the os calcis. 

The upper arrow points to a thickening of the tissue. 



Plate 260 




PLATE 261. 

TUBERCULAR INFECTION OF THE EPIPHYSIS AND OF THE 
SUPERIOR SURFACE OF THE ASTRAGALUS. 

Child, age 4 years. (Life size.) 

A. Abscess within the joint capsule. 

B. Epiphysis showing necrosis of the articular surface. 

C. The astragalus with erosion and destruction of the supe- 

rior surface. 
Note marked re-arrangement of the bone structure of the 
lower end of the tibia, fibula, and tarsus; atrophy of quality 
as well as of size. 



Plate 2(U 




~ 



PLATE 262. 
TUBERCULOSIS OF THE EPIPHYSIS OF THE TIBIA. 

Child, age 5 years. (Life size.) 

A. Abscess. 

B. Erosion of the epiphysis. 

C. Points to the density of the tissues, as compared to that of 

the bone. Bone markedly atrophied in size as well as 
in quality. 

D. Os calcis. 



Plate 262 




I 



PLATE 263. 

ACUTE TUBERCULAR INFECTION OF THE SUPERIOR SURFACE 
OF THE OS CALCIS. 

Boy, age 12 years. (Life size.) 

The arrow points to the area of infection. 



Plate 263 





PLATE 264. 

NON-TUBERCULAR INFECTION ABOUT THE NECK OF 
THE FEMUR. 

Child, age 5 years. 

The arrow points towards an area of absorption in the bone 
about the region of the neck of the femur. No atrophy of the 
shaft or of the epiphysis is noted. 




'■•> : ~. 



Plate 264 



%;,,/ j, 



INDEX 



Abdomen, 141, 142 
Abscess of fibula, 162 

of humerus, 152 

mediastinal, 134 

of os calcis, 214 

of spine, 128 

of thigh, 214 

of tibia, 162 
Abt, 62 
Acetabulum, necrosis, 212 

tubercular, 212 

tuberculous, 212 
Achondroplasia, 81 
Acromion process, epiphysis of, 179 
Adolescence, rhachitis of, 112 
Anatomy, living normal, illustrative use of, 49 
Aneurism, 131, 140 
Ankle, chronic atrophic, 197 

epiphysis of, 179 

rheumatic fever, 186 

tuberculosis of, 215 
Ankylosis of knee, 168 
Anomalies of the extremities, 76, 77 

of the head, 71 

of the pelvis, 80 

of the ribs, 75 

of the spine, 71 

intra-abdominal, 76 

intra-thoracic, 76 
Arm, atrophy of, 154 

china doll's, 136 

chronic atrophic, 197 

normal child 10 years, 45 
Arthritis, infectious, 181 

atrophic variety, 167 

villous, 167 
Ascites, 142 
Astragalus, development of, 31 

exostoses of, 156 

fracture of, 162 

tuberculosis of, 215 



Atelectasis of lung, 133 
Athletics, 64 
Atrophy of arm, 154 

from disuse, 210 

of elbow, 155 

of hand, 154 

infantile, 99 

of quality in tuberculosis, 208 

of shoulder, 154 

of size in tuberculosis, 208 

of wrist, 155 

Bismuth stomach, 141 
Bone, constituents of, 24 
description of, 24 
development of, 26 
examination, 13 
structure of, 14 
Boston Medical and Surgical Journal, obstetri- 
cal paralysis, 91 
Boy, 9 years, normal hands of, 45 
Bronchi, 131 

description of, 133 
Bronchial nodes, 131, 132 
description of, 132 
tuberculosis of, 132 
Bronchoscope, 147 
Brown, Percy, 131, 141 
Buck and Bryant, osteomalacia, 97 

Roentgen pictures of osteomalacia, 98 
Bullard, obstetrical paralysis, 91 

Callus of feet, 156 

Cardiohepatic angle, description of, 23 

significance of, 22 
Carpal bones, tubercular, 211 
Carpus, development of, 28 
Child, five years, normal foot of, 1 1 
labor, 64 

laws, 65 

State laws, 66-68 

219 



220 



INDEX. 



Child, six years, knee of, 45 

normal thorax of, 45 
shoulder of, 45 
skeleton of, 44 
ten years, normal arm of, 45 
normal hand of, 45 
pelvis of, 45 
thorax of, 45 
upper legs of, 45 
three years, knees of, 44 
lower limbs of, 44 
Chondrodystrophia, description of the Roent- 
gen pictures, 86 
examination by Roentgen method, 86 
fcetalis, 81 

cases of, 83 
types, 82 
hyperplastica, 82 
hypoplastica, 82 
malacica, 82 
resume* of, 85 
Clavicle, epiphysis of, 179 
Club-hand, 78 

Coracoid process, epiphysis of, 179 
Cortex, examination, 14 

Crampton, correlation of weight, height, and 
strength with scholarship, 52 
eruption of teeth in 1000 elementary 

school-boys, 53 
growth of pubic hair, 51 
height, weight, appearance of teeth, and 

strength, 51 
menstrual function, 51 
physiologic development correlates closely 
with anatomic normal development, 55 
Cretinism, 80 

recognition of, 83 
Cuboid, development of, 31 
Cuneiform, development of, 29 
external, development of, 31 
internal, development of, 31 
middle, development of, 31 
Cyst, tubercular, 209 

Dactylitis, 199 

syphilitic, 199, 201 

tubercular, 199, 209 
Deformities of jaws, 36 

of lower extremities, 78 



Deformities of upper extremities, 77 
Dentition, first, temporary teeth, 35 

second, permanent teeth, 35 
Development, backward mental, 80 
Diaphyses, description of, 25 
Digit, separate, 77 
Digits, webbed, 77 

Discrepancies of development in anatomies, 59 
Diseases of the head, 115 

of the spine, 123 

of nutrition, 95 
Durante, 84 

Early years, mental care of, 61 

physical care of, 61 
Educators, 62 
Effusion of knee, 185 

pericardial, 139, 140 
Elbow, atrophy of, 155 

epiphysis of, 176 

infant 2-3 months, 41 

normal child 12 years, 46 

osteomyelitis of, 192 

poliomyelitis of, 155 

syphilis of, 200 
Emphysema, 137 

compensatory, 138 
Empyema, encapsulated, 138 
Enamel, formation of, 33 
Epiphyseal cartilage, description of, 27 

line or zone of proliferation, examination, 15 
Epiphysis or epiphyses: — 

of acromion process, 179 

of ankle, 179 

of clavicle, 179 

of coracoid process, 179 

description of, 25 

dislocation of, 159 

of elbow, 176 

examination, 15 

of hip, 178 

of knee, 178 

of os calcis, 179 

of pelvic bones, 179 

of ribs, 179 

of scapula, 179 

of shoulder, 176 

time of appearance, 26 

of vertebrae, 179 



INDEX. 



221 



Epiphysis of wrist, 177 
Epiphysitis, 175 
Ethmoiditis of skull, 116 
Exostoses, 155 

of astragalus, 156 

of femur, 156 

of fibula, 156 

of knee, 156 

of tibia, 156 
Exposure, great advantage of short over long, 

131, 141 
Extremities, the, 149 

anomalies of, 76, 77 

Factories, 65 

Femur, congenital dislocation of, 80 

development of, 29 

dislocation of, 80 

early ossification of, 152 

exostoses of, 156 

intercapsular fracture, 161 

necrosis, 212 

non-tubercular infection, 186 

osteomyelitis of, 190, 192 

tubercular, 212 
Fetal rhachitis, 90 

intra-uterine, 113 
recognition of, 83 
Fibula, abscess of, 162 

development of, 30 

exostoses of, 156 

fracture of, 162 

osteomyelitis of, 196 
First permanent molar, calcification of, 37 
Flat foot, 157 
Foot, backward development of, 151 

normal child 5 years, 44 

one toe, 79 

valgus of, 89 
Foreign bodies, 143 

in intestine, 143-147 
in larynx, 144 
in lung, 144, 147 
in oesophagus, 143 
Fragilitas ossium, 87 

Gangrene, 137 

George, Dr., study of 1000 cases of healthy 
children, 55 



Girl, six months, skeleton of, 41 

twelve months, trunk of, 42 

about twenty-four months, skeleton of, 42 
Gymnastics, 64 

Hand or hands: — 

atrophy of, 154 

chronic atrophic, 197 

infant three months old, 41 

infectious arthritis of, 185 

irregular development of, 149 

normal, child ten years, 45 

normal, boy nine years, 45 

poliomyelitis of, 154 
Head, anomalies of, 71 

diseases of, 115 

infant ten weeks old, 41 

of normal infant, 40 
Healthy children, study of, 55 
Heart, 131 

enlarged, 139 

enlargement of, 139 

transposition of, 132 
Hemorrhage, subperiosteal, 155 
Hip, epiphysis of, 178 

mixed infection, 212 

osteomyelitis of, 191, 194 

tubercular, 212, 213 
Hip-joint, infection of, 181 

mixed infection, 211 
Hour-glass contraction of stomach, 141 
Howship, 97 
Humerus, abscess of, 152 

development of, 27 

displacement of, 159 

fracture of, 159, 160, 161 
of surgical neck of, 160 

infant two to three months, 41 

infectious arthritis of, 185 

osteomyelitis of, 193 
Hydropneumothorax, 137 

Idiot, Mongolian, 135 
Ilium, development of, 32 
Incisors, central, calcification of, 37 

lateral, calcification of, 37 

permanent, calcification of, 87 
Index development, key to, 57 
Infant, head of normal, 40 



222 



INDEX. 



Infant, head of ten weeks old, 41 
premature, description of, 39 
ten days, upper legs of, 40 
ten weeks old, head of, 41 

lower extremity of, 41 
three and a half years, skeleton of, 43 
three months old, hand of, 41 
two to three months, elbows of, 41 
humeri of, 41 
thorax of, 41 
Infantile atrophy, 95, 99 

differential diagnosis from general tu- 
berculosis, 100 
Infection of hip-joint, 181 

non-tubercular, of marrow, 217 
of periosteum, 217 
Infectious arthritis, 181 

atrophic variety, 167 
of hand, 185 
of humerus, 185 
periostitis, 186 
Intestine, congenital malformations of, 141 
fibrous bands of, 141 
nail in, 143 
penny in, 147 
Intra-abdominal anomalies, 76 
Intra-thoracic anomalies, 76 
Intra-uterine rhachitis, 113 
Ischium, development of, 32 

Jaws, deformities of, 36 

osteomyelitis of, 116 
Joints, 163 

atrophic, 196 

classification, 165 

hypertrophic, 196 

original focus, 170 

Kassowitz, rhachitis, 106 
Kaufmann, 81 
Kerley, 62 
Knee, ankylosis of, 168 

child six years, 45 
three years, 44 

chronic atrophic, 197 
atrophy of, 197 

congestion of, 166 

effusion of, 185 

epiphyseal line, 166 



Knee, epiphysis of, 178 

suppuration of, 167 
epiphysitis, 166 
exostoses of, 156 
injury to, 159 
osteochondritis, 166 
rheumatic fever, 186 
villous arthritis, 167 
Knee-joint, dislocation of epiphysis and con- 
dyle, 161 
dislocation and fracture of, 160 
early tuberculosis, 213 
tuberculous, 214 
Konig's collection of infections of the hip- 
joint, 181 
Kyphosis, 126 

La Fetra, plate presented by, plate 240 
Larynx, hook in, 144 
Legg, Dr. A. T., atrophy from disuse, 207 
Legs, congenital paralysis of, 80 

chronic atrophic, 197 

upper, of infant ten days, 40 
of a child ten years old, 45 
Liver, transposition of, 132 
Lordosis, 126 
Lovett, Dr. R. W., 88 
Lower extremities, deformities of, 78 

extremity, delayed development of, Morse's 
case, 79 
infant ten weeks old, 41 

limbs, child three years, 44 
Lungs, 131 

atelectasis of, 133 

collapse of, 134 

compression of, 139 

doll's china arm in, 145 

general description, 133 

nail in, 144 

Malformations of the feet, 77 

of the hands, 77 

of the oesophagus, 141 

of the scapula, 75 

of the stomach, 141 

congenital, of the intestines, 141 
Marrow, non-tubercular infections, 217 
Mediastinal abscess, 134 
Medullary canal, examination, 14 



INDEX. 



223 



Mental care of early years, 61 

development, backward, 80 
Metacarpal bones, development of, 29 
Metatarsal bones, absent, 79 
tuberculosis in, 209 
Metatarsus, development of, 31 
Molar, first permanent, development of, 37 

calcification of, 37 
Mongolian idiot, 135 
Morse, patient of, plate 57 
Mullen's case of osteogenesis imperfecta, 85 
Muller, rhachitis, 106 
Muscle, examination, 13 
Myxcedema, 80 

New-born, diseases of, 69 

Nichols, 88 

Nodes, bronchial, 132 

mesenteric, 142 
Non-tubercular infections, 215 

of femur, 186 

of marrow, 217 

of spine, 126 

location of, 216 

Roentgen ray in, 217 
Normal living anatomy, chronologic examples 

of, 38 
Nutrition, diseases of, 95 

Obstetrical paralysis, 90 
(Esophagus, malformations of, 141 

penny in, 143 
Os calcis, abscess of, 214 

development of, 31 
epiphysis of, 179 
fracture of epiphysis, 163 
tubercular, 214 
innominatum, development of, 32 
magnum, development of, 28 
pubis, development of, 32 
Osgood, 108 
Osteitis of spine, 126 

tubercular, 127 
Osteochondritis, syphilis in, 201 
Osteogenesis imperfecta, British Medical Jour- 
nal, 89 
comparison with osteomalacia, 98 
Lovett's case of, 88 
Mullen's case of, 85 



Osteogenesis imperfecta, Nichols' case of, 88 
recognition of, 83 
synonyms of, 87 
Osteomalacia, 95, 96 

comparison with osteogenesis imperfecta, 98 
Osteomyelitis, 187 

of elbow, 192 

of femur, 190, 191, 192 

of fibula, 196 

of hip, 191 

of humerus, 193 

of jaw, 116 

of radius, 193 

of spine, 126, 127 

of tibia, 189-191 
Osteoperiostitis, syphilis in, 201 
Osteoporosis, 82 
Osteopsathyrosis, idiopathic, 87 
Osteosclerosis, 82 

Paralysis, obstetrical, 90 
Parrot, 81 

Patella, development of, 30 
Pelvic bones, epiphyses of, 179 
Pelvis, anomalies of, SO 

normal child ten years, 45 
Pericardium, 131, 139 

Periosteum, acute infections by pyogenic or- 
ganisms, 217 

description of, 24 

examination, 15 
Periostitis of spine, 126 

syphilitic, 201 
Permanent incisors, calcification of, 37 

teeth, 35 
Phalanges, development of, 29, 31 
Physical care of early years, 61 
Pimmes, rhachitis, 106 
Pisiform, development of, 29 
Pleura, 131, 137 
Pneumonia, broncho-, 136 

lobar, 135 

unresolved, 135 
Pneumothorax, 137 
Poliomyelitis, 154 

of elbow, 155 

of hand, 154 

of shoulders, 154 

of wrist, 155 



224 



INDEX. 



Porier, 60 

Postpubescents, height of, 52 

scholarship of, 52 

strength of, 52 

weight of, 52 
Pott's disease, 125 
Precocious and bright children, 63 
Premature infant, description of, 39 
Prepubescents, scholarship of, 52 
Primary areolae, 27 
Pryor, 58 

Radius, deformity of, 78 

development of, 28 

fracture of, 162 

green-stick fracture, 161 

impacted fracture, 161 

osteomyelitis of, 193 
Rhachitis, 95 

of adolescence, 112 

compared with chondrodystrophia fcetalis, 
107 

description of, 104 

epiphysis and zone of proliferation, 108 

fetal, 90 

fracture, 109 

general structure of the bone, 108 

Kassowitz, 106 

marked deformities of, 109 

medullary canal, 108 

Muller, 106 

osseous system, 108 

with osteomalacia, 107 

outline of the cortex and periosteum, 108 

Pimmes, 106 

types of, 110 

Vierordt, 106 

Virchow, 106 

Ziegler, 106 

zone of proliferation, 107 
Rheumatic fever of ankle, 186 

of knee, 186 
Ribs, anomalies of, 75 

collapsed, 138 

epiphyses of, 179 
Roentgen method, determination of teeth by. 
38 
Rotch method of study of develop- 
ment by, 56 



Roentgen plate, 8 

ray in dentistry, 33 

Sacro-iliac joint, tubercular process of, 128 
Sarcoma, medullary, 153 

myelogenous, 153 

periosteal, 154 
Scaphoid, delayed development, 151 

development of, 29, 31 
Scapula, elevation of, 76 

epiphysis of, 179 

malformations of, 75 
Scoliosis, 126 
Scorbutus, 95 

hemorrhage in, 100 

Roentgenograph compared with sarcoma, 
103 
Semilunar, development of, 29 
Shoulder, atrophy of, 154 

child six years, 45 

epiphyses of, 176 

poliomyelitis of, 154 
Skeleton, child about six years, 44 

girl six months, 41 

about twenty-four months, 42 

infant about three and a half years, 43 

normal child twelve years, 46 
Skull, ethmoiditis of, 116 

fracture of, 115 
Spina bifida, 73 

occulta, 74 
Spine, abscess of, 128 

anomalies of, 71 

diseases of, 123 

non-tubercular infections of, 126 

normal child ten years, 46 

osteitis of, 126 

osteomyelitis of, 126, 127 

periostitis of, 126 

tuberculosis of, 127 
Stomach, bismuth, 141 

hour-glass contraction, 141 

malformations of, 141 
Stone, 157 

Stransky, obstetrical paralysis, 91 
Structure of the bone, examination, 14 
Stupid children, 64 
Subcutaneous tissue, examination, 13 
Subperiosteal hemorrhage, 155 



INDEX. 



225 



Supernumerary teeth, 119 
Syphilis, 198 

of elbow, 200 

retarded, 202 

of tibia, 201 

of ulna, 200 
Syphilitic osteochondritis, 201 

osteoperiostitis, 201 

periostitis, 201 

Tarsus, development of, 31 
Teeth, 32 

normal permanent, 47 

permanent, 35 

normal development of, 38 

supernumerary, 119 

temporary, 35 

separation of, 36 
Thigh, abscess of, 214 

subperiosteal hemorrhage of, 155 
Thomas, 91 
Thorax, infant, ten days, 40 

two to three months, 41 

normal boy twelve years, 46 
child, six years, 45 
ten years, 45 
Tibia, abscess of, 162 

development of, 30 

early ossification of, 152 

epiphysis, 214 

suppuration of, 167 

exostoses of, 156 

fracture of, 162, 163 

green-stick fracture, 160 

osteomyelitis of, 189, 191 

early stages of infection, 196 

syphilis of, 201 

tubercular, 214 
Tissues, atomic weight of, 8 

elements of, 8 

radiability of, 8 

subcutaneous, examination of, 13 
Torticollis, 75 

Trapezium, development of, 29 
Trapezoid, development of, 29 
Traumatism, 157 

technic of, 158, 159 



Trunk, girl twelve months, 42 
Tubercular dactylitis, 199, 209, 210 
Tuberculosis, 137, 202 

of acetabulum, 212 

acute miliary, 136, 137 

of ankle, 215 

of astragalus, 215 

atrophy in, 204, 205, 206, 207 
of quality in, 208 

of bronchial nodes, 132 

of carpus, 211 

cyst, 209 

of elbow, 211 

of hip-joint, 211, 212 

of knee, 213 

of metatarsus, 209 

of os calcis, 214, 215 

of spine, 127 

Ulna, deformity of, 78 

development of, 28 

fracture of, 162 

impacted fracture of, 161 

necrosis of, 211 

syphilis of, 200 
Unciform, development of, 28 
Upper extremities, deformities of, 77 

legs, infant ten days, 40 

normal child ten years, 45 
Urethra, stone in, 143 

Valgus of foot, 89 
Vertebrae, epiphyses of, 179 
Vierordt, rhachitis, 106 
Villous arthritis, 167 
Virchow, rhachitis, 106 

Wolff's law, 110, 111 
Wrist, anomaly of, 150 

atrophy of, 155 

chronic atrophic, 197 

epiphysis of, 177 

poliomyelitis of, 155 

Ziegler, osteomalacia, 96 

rhachitis, 106 
Zone of proliferation, description of, 27 



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